Provider Demographics
NPI:1861453763
Name:SPENGLER, MARY (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SPENGLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3366 OAKDALE AVENUE NORTH
Mailing Address - Street 2:# 315 NORTH CLINIC PA
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422
Mailing Address - Country:US
Mailing Address - Phone:763-587-7900
Mailing Address - Fax:763-587-7989
Practice Address - Street 1:3366 OAKDALE AVENUE NORTH
Practice Address - Street 2:SUITE 315
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422
Practice Address - Country:US
Practice Address - Phone:763-587-7900
Practice Address - Fax:763-587-7989
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0905150363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN773032200Medicaid
MN773032200Medicaid
500001067Medicare PIN