Provider Demographics
NPI:1730588823
Name:RADKE, TIFFANY J (APN)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:J
Last Name:RADKE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 UNIVERSITY AVE W FL 1
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3727
Mailing Address - Country:US
Mailing Address - Phone:651-232-2002
Mailing Address - Fax:
Practice Address - Street 1:1700 UNIVERSITY AVE W FL 1
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3727
Practice Address - Country:US
Practice Address - Phone:651-232-2002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-011702363L00000X
MN5391363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner