Provider Demographics
NPI:1285143529
Name:MENKOSKY, TERRA MICHELE (PA)
Entity type:Individual
Prefix:
First Name:TERRA
Middle Name:MICHELE
Last Name:MENKOSKY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TERRA
Other - Middle Name:M
Other - Last Name:FODSTAD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:900 LONG LAKE RD STE 150
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-6414
Mailing Address - Country:US
Mailing Address - Phone:612-213-2370
Mailing Address - Fax:612-524-5571
Practice Address - Street 1:900 LONG LAKE RD STE 150
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-6414
Practice Address - Country:US
Practice Address - Phone:612-213-2370
Practice Address - Fax:612-524-5571
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6912363A00000X
MN14042363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant