Provider Demographics
NPI:1528844933
Name:PAULSEN, PAUL OTTO JONAS
Entity type:Individual
Prefix:
First Name:PAUL OTTO JONAS
Middle Name:
Last Name:PAULSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20307 JUPITER WAY
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-7829
Mailing Address - Country:US
Mailing Address - Phone:720-343-0724
Mailing Address - Fax:
Practice Address - Street 1:20307 JUPITER WAY
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-7829
Practice Address - Country:US
Practice Address - Phone:720-343-0724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2489614367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered