Provider Demographics
NPI:1922115849
Name:GUNDERSON, RENEE ANNE (PAC)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:ANNE
Last Name:GUNDERSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:ANNE
Other - Last Name:DANIELZUK MCKEEVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:3359 WILDWOOD TRL NW
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-3267
Mailing Address - Country:US
Mailing Address - Phone:612-532-2414
Mailing Address - Fax:
Practice Address - Street 1:1575 BEAM AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1126
Practice Address - Country:US
Practice Address - Phone:651-232-7348
Practice Address - Fax:651-232-6665
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9265363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNS75632Medicare UPIN