Provider Demographics
NPI:1669451688
Name:SWANSON, PENELOPE J (MD)
Entity Type:Individual
Prefix:
First Name:PENELOPE
Middle Name:J
Last Name:SWANSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8674
Mailing Address - Street 2:1230 E MAIN ST
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56002-8674
Mailing Address - Country:US
Mailing Address - Phone:507-625-1811
Mailing Address - Fax:
Practice Address - Street 1:1421 PREMIER DR
Practice Address - Street 2:
Practice Address - City:MANAKATO
Practice Address - State:MN
Practice Address - Zip Code:56001
Practice Address - Country:US
Practice Address - Phone:507-625-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44271207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
2409708OtherAMERICAS PPO MN
41084933956001G010OtherCHAMPUS
NA2951040749OtherPREFERRED ONE MN
796S7SWOtherBCBS MN
0801074OtherMEDICA MN
MN448032500Medicaid
HP41128OtherHEALTH PARTNERS MN
166247OtherUCARE MN
IA0586008Medicaid
P00144651OtherRR MEDICARE
HP41128OtherHEALTH PARTNERS MN
41084933956001G010OtherCHAMPUS