Provider Demographics
NPI:1740631415
Name:EGGERSGLUESS, CAROL JO (NP-C)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:JO
Last Name:EGGERSGLUESS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13475 COUNTY ROAD 2
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:MN
Mailing Address - Zip Code:55336-7703
Mailing Address - Country:US
Mailing Address - Phone:952-240-4048
Mailing Address - Fax:
Practice Address - Street 1:13475 COUNTY ROAD 2
Practice Address - Street 2:
Practice Address - City:GLENCOE
Practice Address - State:MN
Practice Address - Zip Code:55336-7703
Practice Address - Country:US
Practice Address - Phone:952-240-4048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP 4570363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNCNP 4570Medicaid
MNCNP 4570Medicare PIN