Unknown Individual – Physician Assistant, NPI 1689640146

Physician Assistant

Unknown Individual is a healthcare provider. based in Waite park, Minnesota. specializing in Physician Assistant. They hold a License No. 9224 (MN). The NPI Number for Unknown Individual is 1689640146

Main info

Organization

Inactive

35 Years Of Experience

Accepts Medicare Assignment

Name

Unknown Individual

NPI

1689640146

Phone

(320) 203-2400

Address

430 Great Oak Dr

Deactivation Date

29 November 2023

Doctor Profile

Medical School Name

OTHER

Secondary Phone

6123711600

Graduation Year

1991 (35 years ago)

PAC ID

8426188236

Group Practice PAC ID

1759293954

Professional Enrollment ID

I20100604000525

Data current as of

19 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology

Experience14

Completeness75

Years active:0State licenses:1Digital endpointsOther names

Provider Addresses for Unknown Individual

430 Great Oak Dr
Waite Park, MN 563872504
Phone: (320) 203-2400
Fax: (320) 251-1604
Type: Location
8170 33RD AVE S # MS 21110Q
MINNEAPOLIS, MN 554254516
Phone:
Type: Mailing
430 GREAT OAK DR
WAITE PARK, MN 563872504
Phone: (320) 203-2400
Fax: (320) 251-1604
Type: Location
34th Avenue South, Bloomington, Hennepin County, Minnesota, 55425, United States
MC21110Q
BLOOMINGTON, MN 554251672
Phone: (952) 883-7172
Fax: (952) 883-5395
Type: Mailing
SCTCC Health Sciences Building, 1245, 15th Street North, Saint Cloud, Stearns County, Minnesota, 56303, United States
ST CLOUD, MN 563031802
Phone: (320) 253-5200
Fax: (320) 203-2113
Type: Location

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.

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Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

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 56387)

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Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.

PAC ID: 1759293954View full group profile

Name	Specialty	State
MRS. CHERYL ELIZABETH SETTIMI (CNP)	-	MN
AARON MEANS	Clinical Psychologist	MN
DR. MARY DELLING MCLAURIN (MD)	-	MN
SCOTT A OAKMAN (MD)	P S Y C H I A T R Y	MN
DR. OLADEPO COLLINS FASORANTI (MBBS)	Family Practice	MN
Unknown Individual	-	MN
ANDREA BERGSTROM (NP)	-	MN
DR. RACHEL CAROLYN COLLIER (DPM)	P O D I A T R Y	MN
MS. RUTH ANN HOFFMAN (PA-C)	Physician Assistant	MN
TOVA ELISE LYNG	Physician Assistant	MN