Provider Demographics
NPI:1669447215
Name:RADIN, BARRY A (PAC)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:A
Last Name:RADIN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 NORTHWAY DR
Mailing Address - Street 2:STE 103
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1262
Mailing Address - Country:US
Mailing Address - Phone:320-267-1341
Mailing Address - Fax:
Practice Address - Street 1:1245 15TH ST N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1802
Practice Address - Country:US
Practice Address - Phone:320-253-5200
Practice Address - Fax:320-203-2113
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8819363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN512636300Medicaid
970000570Medicare ID - Type Unspecified
MN512636300Medicaid