Provider Demographics
NPI:1932416435
Name:PALOKANGAS, GLEN DAVID (APRN, CRNA)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:DAVID
Last Name:PALOKANGAS
Suffix:
Gender:M
Credentials:APRN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 SKYLINE BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-1199
Mailing Address - Country:US
Mailing Address - Phone:218-879-4641
Mailing Address - Fax:
Practice Address - Street 1:512 SKYLINE BLVD STE 1
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1199
Practice Address - Country:US
Practice Address - Phone:218-879-4641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-03
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR155380-2367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN430007324Medicare PIN