Provider Demographics
NPI:1609464734
Name:DEMARCO, KAELI MIKEL
Entity type:Individual
Prefix:
First Name:KAELI
Middle Name:MIKEL
Last Name:DEMARCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 CAMPUS DR STE 10
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-2669
Mailing Address - Country:US
Mailing Address - Phone:763-236-6000
Mailing Address - Fax:
Practice Address - Street 1:2800 CAMPUS DR STE 20
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-2669
Practice Address - Country:US
Practice Address - Phone:763-236-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-05
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MN14230363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant