Basic Information
| Provider Information | |||||||||
| NPI: | 1770711863 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURGOS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 BUNKER HILL DR | ||||||||
| Address2: | |||||||||
| City: | AITKIN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564311865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2189272157 | ||||||||
| FaxNumber: | 2189274130 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 BUNKER HILL DR | ||||||||
| Address2: | |||||||||
| City: | AITKIN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564311865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2189272157 | ||||||||
| FaxNumber: | 2189274130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2009 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R164473-7 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1770711863 | 05 | MN | MEDICAID |