Provider Demographics
NPI:1013901875
Name:KOSEVICH, GWENDOLYN MARTINIQUE (MSN)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:MARTINIQUE
Last Name:KOSEVICH
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:651-495-6603
Mailing Address - Fax:952-853-8727
Practice Address - Street 1:295 PHALEN BLVD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-2400
Practice Address - Country:US
Practice Address - Phone:651-495-6603
Practice Address - Fax:651-495-6201
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1237131363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily