Provider Demographics
NPI:1821172057
Name:NICK, MARY (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:NICK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 DELAWARE ST SE
Mailing Address - Street 2:MMC 480-UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-625-2654
Mailing Address - Fax:
Practice Address - Street 1:420 DELAWARE ST SE
Practice Address - Street 2:MMC 480-UNIVERSITY OF MINNESOTA PHYSICIANS
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-625-2654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9941363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN13265OtherUCARE
MNHP49622OtherHEALTHPARTNERS
MN01-06279OtherMEDICA-PRIMARY
MN1043048OtherPREFERRED ONE
MN856458100Medicaid
MN01-19052OtherMEDICA-CHOICE
MN2319537OtherARAZ
MT4304742Medicaid
WI41999800Medicaid
MT4304742Medicaid
WI41999800Medicaid