NPIMap

Individual provider Active NPI

Nicole Elizabeth Fogt, PA-C

  • Medical Physician Assistant
  • Saint Cloud, MN
National Provider Identifier
1770909749
Registry record updated Apr 1, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medical Physician AssistantTaxonomy code 363AM0700X
License
11514 Issued in MN
Practice address
1200 6TH Ave N
Centracare Clinic
Saint Cloud, MN 56303-2735
Phone
(320) 656-7020
NPI assigned
Mar 13, 2014
Last updated
Apr 1, 2014By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Apr 1, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 11514 MN
Medical Physician Assistant 363AM0700X 11514 MN Primary

Addresses

Primary practice location

1200 6TH Ave N
Centracare Clinic
Saint Cloud, MN 56303-2735

Mailing address

1200 6TH Ave N
Centracare Clinic
Saint Cloud, MN 56303-2735
Phone (320) 656-7020

Other names 1

  • Nicole Elizabeth Larson Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20140422001576 MN Practitioner - Physician Assistant 3870725013 Reassigns benefits to 3 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2013
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Centracare ClinicGroup PAC ID 2466363395, 800 clinicians

Practice addresses (Care Compare)

1200 6TH Ave N
Saint Cloud, MN 56303-2735

1200 6TH N Ave
Saint Cloud, MN 56303-2735
Phone (320) 252-5131

1406 6TH Ave N
St Cloud, MN 56303-1901

1406 6TH Ave No
St Cloud, MN 56303-1901

1900 Centracare Cir
Saint Cloud, MN 56303-5000

612 S Sibley Ave
Meeker County Memorial Hospital
Litchfield, MN 55355-3340
Phone (320) 693-3242

PO Box
Chicago, IL 60673

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled

State licenses

LicenseStateTypeSpecialty
11514MNMDPhysical Therapist

Practice roles

OrganizationSpecialtyStatusNew patients
Centracare Clinic CurrentSince Mar 31, 2014 Accepting new patients
Centracare Health System-NR LLC CurrentSince Sep 1, 2019 Accepting new patients
Centracare Clinic CurrentSince Mar 31, 2014 Accepting new patients
Centracare Clinic Past Accepting new patients
Centracare Clinic Past Accepting new patients

Locations

1013 Hart Blvd
Monticello, MN 55362
Phone (763) 271-2303

1200 6th Ave N
Saint Cloud, MN 56303
Phone (320) 252-3342

1900 Centracare Cir
Saint Cloud, MN 56303
Phone (320) 252-2422

Interoperability endpoints

  • Direct secure messaging: nfogt183160@direct.centracare.com

Organizations & group practices 7

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 13

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 13

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1394668800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1396310400000",
    "number": "1770909749",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1200 6TH AVE N",
            "address_2": "CENTRACARE CLINIC",
            "city": "SAINT CLOUD",
            "state": "MN",
            "postal_code": "563032735",
            "telephone_number": "320-656-7020"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1200 6TH AVE N",
            "address_2": "CENTRACARE CLINIC",
            "city": "SAINT CLOUD",
            "state": "MN",
            "postal_code": "563032735",
            "telephone_number": "320-656-7020"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FOGT",
        "first_name": "NICOLE",
        "middle_name": "ELIZABETH",
        "name_prefix": "Mrs.",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2014-03-13",
        "last_updated": "2014-04-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "MN",
            "license": "11514",
            "primary": false
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "MN",
            "license": "11514",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "NICOLE",
            "last_name": "LARSON",
            "middle_name": "ELIZABETH",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Saint Cloud, MN

Sources for this page

Verify at the official NPI Registry.