Provider Demographics
NPI:1821180712
Name:MANECKE, NICOLE THERESE (PA)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:THERESE
Last Name:MANECKE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:THERESE
Other - Last Name:REICHMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13359 ISLE DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-2222
Mailing Address - Country:US
Mailing Address - Phone:218-454-7546
Mailing Address - Fax:
Practice Address - Street 1:13359 ISLE DR
Practice Address - Street 2:SUITE 3
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-2222
Practice Address - Country:US
Practice Address - Phone:218-454-7546
Practice Address - Fax:218-454-3062
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-001851363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1720269426OtherDERMATOLOGY PROFESSIONALS, PA TYPE 2 NPI