Provider Demographics
NPI:1801645296
Name:PERERVA, DENIS
Entity type:Individual
Prefix:
First Name:DENIS
Middle Name:
Last Name:PERERVA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6701 RICHFIELD PKWY APT C217
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-7525
Mailing Address - Country:US
Mailing Address - Phone:612-205-1745
Mailing Address - Fax:
Practice Address - Street 1:2211 RIVERSIDE AVE
Practice Address - Street 2:PO BOX 149
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1350
Practice Address - Country:US
Practice Address - Phone:612-330-1399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-16
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1170-2204-1472146L00000X
363A00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant