CARLY JO HENNEK (PA-C) – Physician Assistant, NPI 1023824406
Physician Assistant
Main info
Doctor Profile
Profile Insights
NPPES metrics only — not quality of care.
4,031 PHYSICIAN ASSISTANT in MN
Provider Addresses for CARLY JO HENNEK (PA-C)
2720 FAIRVIEW AVE N STE 200
ROSEVILLE, MN 551131306
Phone: (651) 633-6883
Fax: (651) 331-3459
Mailing address matches the actual address.
NPPES updates history
No NPPES updates recorded for this provider.
Prescription Activity
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Open Payments (CMS)
No Open Payments data available for this provider.
This can happen when there are no reportable CMS Open Payments records.
Medicare Enrollment & Revalidation
Source: CMS public data · Not endorsed by CMS ·
Educational use only—not medical, billing, or legal advice.
PECOS enrollment status
Participating (accepts Medicare assignment)
Enrollment effective: 2025-03-19
PECOS data refreshed: 2026-05-27
Medicare revalidation (CMS due date list)
Due date not assigned yet
CMS is tracking 2 Medicare enrollment records; no due dates published yet.
Enrollment records
2
Earliest due date
Not assigned (TBD)
CMS data updated
2026-06-01
Revalidation progress
- Medicare enrolled
- On CMS revalidation list
- Due date assigned
- Revalidate in PECOS
CMS enrollment records
| Enrollment ID | Type | Specialty | State | Due date |
|---|---|---|---|---|
| I20250228000807 | I | Physician Assistant | MN | TBD |
| I20250319003162 | I | Physician Assistant | WI | TBD |
What to do next
- No action required while the due date shows TBD.
- Check the CMS Revalidation Lookup Tool periodically — CMS updates the list about every 60 days.
- Do not submit a revalidation application in PECOS until CMS publishes a concrete due date.
Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS
Medicare Utilization (FFS)
Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·
Educational use only—not medical, billing, or legal advice.
No Medicare fee-for-service utilization data available for this provider in our database.
Insurance plans in this area (ZIP 55113)
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Group practice members
| Name | Specialty | State |
|---|---|---|
| D E R M A T O L O G Y | MN | |
| D E R M A T O L O G Y | MN | |
| Physician Assistant | MN | |
| Physician Assistant | MN | |
| P O D I A T R Y | WI | |
| Physician Assistant | MN | |
| P A T H O L O G Y | IL | |
| Physician Assistant | MN | |
| P A T H O L O G Y | CT | |
| D E R M A T O L O G Y | MN |
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