Provider Demographics
NPI:1295983203
Name:MARWA, MILLICENT JULIA (MS-PAS, PA-C)
Entity type:Individual
Prefix:
First Name:MILLICENT
Middle Name:JULIA
Last Name:MARWA
Suffix:
Gender:F
Credentials:MS-PAS, PA-C
Other - Prefix:
Other - First Name:MILLICENT
Other - Middle Name:JULIA MARWA
Other - Last Name:HOLMSTROM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4240 PARK GLEN RD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5427
Mailing Address - Country:US
Mailing Address - Phone:612-925-6033
Mailing Address - Fax:612-925-8496
Practice Address - Street 1:4027 COUNTY ROAD 25
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-2629
Practice Address - Country:US
Practice Address - Phone:612-925-6033
Practice Address - Fax:612-925-8496
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10466363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1179OtherMINNESOTA BOARD OF MEDICAL PRACTICE - PHYSICIAN ASSISTANT