Provider Demographics
NPI:1982150728
Name:PARK NICOLLET
Entity type:Organization
Organization Name:PARK NICOLLET
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HTCP
Authorized Official - Prefix:
Authorized Official - First Name:SOFIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:TSUKERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-494-4686
Mailing Address - Street 1:7102 OLIVE LANE NORTH
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9555 UPLAND LN N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:66369
Practice Address - Country:US
Practice Address - Phone:952-993-1589
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL 48617-4261Q00000X, 261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical