Provider Demographics
NPI:1821352642
Name:PAULUS, JESSE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:PAULUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5807 SHERIDAN AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-2952
Mailing Address - Country:US
Mailing Address - Phone:612-532-0752
Mailing Address - Fax:
Practice Address - Street 1:6401 FRANCE AVE S
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2104
Practice Address - Country:US
Practice Address - Phone:952-924-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-26
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR173756-3163W00000X
390200000X
MN90394367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program