Provider Demographics
NPI:1023493103
Name:BIRNO, NATHAN AMBROSE (PA-C)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:AMBROSE
Last Name:BIRNO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:218-786-8364
Mailing Address - Fax:
Practice Address - Street 1:400 E 3RD ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1951
Practice Address - Country:US
Practice Address - Phone:218-786-8364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-30
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5257-23363A00000X
363A00000X
MN11930363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant