Provider Demographics
NPI:1649328121
Name:KULUS, JENNIFER MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:KULUS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:19957 DOVER DRIVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024
Mailing Address - Country:US
Mailing Address - Phone:651-463-2323
Mailing Address - Fax:
Practice Address - Street 1:FAIRVIEW URGENT CARE - EAGAN
Practice Address - Street 2:1440 DUCKWOOD DRIVE
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122
Practice Address - Country:US
Practice Address - Phone:651-406-8860
Practice Address - Fax:651-406-8870
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1068165363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant