NPIMap

Individual provider Active NPI

Jennifer Poethke Idiculla, PA-C

  • Physician Assistant
  • Saint Michael, MN
National Provider Identifier
1841661824
Registry record updated Jan 12, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
1289 Issued in MN
Practice address
4300 Edgewood Dr NE
Saint Michael, MN 55376-4588
Phone
(763) 744-4000
NPI assigned
Oct 15, 2015
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jan 12, 2023

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 1289 MN Primary

Addresses

Primary practice location

4300 Edgewood Dr NE
Saint Michael, MN 55376-4588

Mailing address

2925 Chicago Ave
Minneapolis, MN 55407-1321
Phone (612) 262-9000

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
I20171101002339 MN Practitioner - Physician Assistant 8426358284 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2015
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Allina Health SystemGroup PAC ID 4587573613, shared by 89 NPIs, 3,844 clinicians

Practice addresses (Care Compare)

4300 Edgewood Dr NE
St Michael, MN 55376-4588
Phone (763) 744-4000

440 Elm St E
Annandale, MN 55302-1109
Phone (320) 682-5225

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
12489MNMDClinical Social Worker

Practice roles

OrganizationSpecialtyStatusNew patients
Allina Health System CurrentSince Oct 30, 2017 Accepting new patients
Allina Health System CurrentSince Dec 31, 2022 Accepting new patients
Allina Health System CurrentSince Oct 30, 2017 Accepting new patients
Allina Health System Past Accepting new patients

Locations

440 Elm St E
Annandale, MN 55302
Phone (320) 682-5225

2925 Chicago Ave
#10957
Minneapolis, MN 55407
Phone (612) 262-8640

2215 Park Ave
Minneapolis, MN 55404
Phone (612) 775-8800

2925 Chicago Ave
Minneapolis, MN 55407
Phone (612) 262-4813

4300 Edgewood Dr NE
Saint Michael, MN 55376
Phone (763) 744-4000

1021 Bandana Blvd E
Ste 100
Saint Paul, MN 55108
Phone (877) 414-2533

150 Emerson Ave E
West St Paul, MN 55118
Phone (651) 241-1800

Interoperability endpoints

  • Direct secure messaging: jpoethke378817@excellian.direct.allina.com

Organizations & group practices 6

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

Hospital & facility affiliations 32

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

View all 32

NPI Registry JSON

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

{
    "created_epoch": "1444867200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1673481600000",
    "number": "1841661824",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2925 CHICAGO AVE",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554071321",
            "telephone_number": "612-262-9000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4300 EDGEWOOD DR NE",
            "city": "SAINT MICHAEL",
            "state": "MN",
            "postal_code": "553764588",
            "telephone_number": "763-744-4000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "IDICULLA",
        "first_name": "JENNIFER",
        "middle_name": "POETHKE",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2015-10-15",
        "last_updated": "2023-01-12",
        "certification_date": "2023-01-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "MN",
            "license": "1289",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Saint Michael, MN

Sources for this page

Verify at the official NPI Registry.