Provider Demographics
NPI:1295701548
Name:CICHANOWSKI, HEATHER R (MD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:R
Last Name:CICHANOWSKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:435 PHALEN BLVD
Mailing Address - Street 2:MAIL STOP 51103H
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55130-5302
Mailing Address - Country:US
Mailing Address - Phone:651-254-8300
Mailing Address - Fax:651-254-8379
Practice Address - Street 1:435 PHALEN BLVD
Practice Address - Street 2:MAIL STOP 51103H
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-5302
Practice Address - Country:US
Practice Address - Phone:651-254-8300
Practice Address - Fax:651-254-8379
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI46784020207Q00000X
MN44664207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN177272400Medicaid
H63769Medicare UPIN
080014371Medicare ID - Type Unspecified