Provider Demographics
NPI:1558080929
Name:POPKO, JONATHAN STANLEY (CNP)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:STANLEY
Last Name:POPKO
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3215 E 24TH ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-1405
Mailing Address - Country:US
Mailing Address - Phone:612-562-5880
Mailing Address - Fax:
Practice Address - Street 1:606 24TH AVE S STE 602
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1438
Practice Address - Country:US
Practice Address - Phone:612-672-2450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-26
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9456363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty