Provider Demographics
NPI:1932205408
Name:FEDUNOK, PAULINE A (PA-C)
Entity type:Individual
Prefix:MS
First Name:PAULINE
Middle Name:A
Last Name:FEDUNOK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:PAULINE
Other - Middle Name:A
Other - Last Name:FEDUNOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:420 DELAWARE STREET, SE
Mailing Address - Street 2:MAYO BLDG, MMC B537
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-625-6401
Mailing Address - Fax:612-676-4041
Practice Address - Street 1:500 HARVARD ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0363
Practice Address - Country:US
Practice Address - Phone:126-273-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11377363AS0400X
IN01052755A363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP95337Medicare UPIN