Provider Demographics
NPI:1194122713
Name:PRONK, MARICIA JOY (PA-C)
Entity type:Individual
Prefix:
First Name:MARICIA
Middle Name:JOY
Last Name:PRONK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 4TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:PIPESTONE
Mailing Address - State:MN
Mailing Address - Zip Code:56164-1890
Mailing Address - Country:US
Mailing Address - Phone:507-825-5811
Mailing Address - Fax:
Practice Address - Street 1:916 4TH AVE SW
Practice Address - Street 2:
Practice Address - City:PIPESTONE
Practice Address - State:MN
Practice Address - Zip Code:56164-1890
Practice Address - Country:US
Practice Address - Phone:507-825-5811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-25
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11748363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant