1194903575 NPI number — LISA M STENSRUD PT

Table of content: LISA M STENSRUD PT (NPI 1194903575)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194903575 NPI number — LISA M STENSRUD PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STENSRUD
Provider First Name:
LISA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SCHMIDT
Provider Other First Name:
LISA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194903575
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
05/04/2023
NPI Reactivation Date:
05/18/2023

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 1ST ST SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55905-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-284-2511
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
39 S MAYSVILLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT STERLING
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40353-1354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-520-3171
Provider Business Practice Location Address Fax Number:
859-520-3289
Provider Enumeration Date:
02/07/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  8021 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P01021860 . This is a "MCR RAILROAD MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: ENROLLED , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".