Provider Demographics
NPI:1104529767
Name:SZALAT, JACOB THOMAS (PA-C)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:THOMAS
Last Name:SZALAT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 AMERICAN BLVD W STE 300
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-4442
Mailing Address - Country:US
Mailing Address - Phone:952-512-5600
Mailing Address - Fax:
Practice Address - Street 1:4010 W 65TH ST
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-1706
Practice Address - Country:US
Practice Address - Phone:952-456-7000
Practice Address - Fax:952-456-7001
Is Sole Proprietor?:No
Enumeration Date:2023-03-23
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN15029363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant