Provider Demographics
NPI:1194701102
Name:OELTJENBRUNS, CHERYL LYNN (PAC)
Entity type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:LYNN
Last Name:OELTJENBRUNS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 W 66TH ST STE 150
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2109
Mailing Address - Country:US
Mailing Address - Phone:952-920-7200
Mailing Address - Fax:763-302-4234
Practice Address - Street 1:3400 W 66TH ST STE 150
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2109
Practice Address - Country:US
Practice Address - Phone:952-920-7200
Practice Address - Fax:763-302-4234
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9323363AS0400X, 363A00000X
WI1951363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNS49875Medicare UPIN
MN970002464Medicare PIN
MN919630700Medicaid
WI56080-0031Medicare PIN
MN0572890001Medicare NSC
WI42970400Medicaid
WI49128-0030Medicare PIN