Provider Demographics
NPI:1679657001
Name:POQUETTE, GREGG MICHAEL (DC)
Entity type:Individual
Prefix:DR
First Name:GREGG
Middle Name:MICHAEL
Last Name:POQUETTE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 SLATER RD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-4047
Mailing Address - Country:US
Mailing Address - Phone:651-452-3900
Mailing Address - Fax:651-452-3901
Practice Address - Street 1:4660 SLATER RD
Practice Address - Street 2:SUITE 140
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-4047
Practice Address - Country:US
Practice Address - Phone:651-452-3900
Practice Address - Fax:651-452-3901
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2402111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN344328100Medicaid
MN51364POOtherBLUE CROSS
MN344328100Medicaid