Provider Demographics
NPI:1144280280
Name:BAUMGARD, CONNIE S (NP)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:S
Last Name:BAUMGARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:S
Other - Last Name:HOMEISTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:MR 10809
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-4813
Mailing Address - Fax:612-262-4194
Practice Address - Street 1:MR 10809
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55440-0043
Practice Address - Country:US
Practice Address - Phone:612-262-4813
Practice Address - Fax:612-262-4194
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 120770-5363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
S93077Medicare UPIN