1154509479 NPI number — MINDY S STAVETEIG PA-C

Table of content: MINDY S STAVETEIG PA-C (NPI 1154509479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154509479 NPI number — MINDY S STAVETEIG PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STAVETEIG
Provider First Name:
MINDY
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ANDERSON
Provider Other First Name:
MINDY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1154509479
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 S MINNESOTA STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CROOKSTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56716
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-587-6000
Provider Business Mailing Address Fax Number:
701-587-6009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 S MINNESOTA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CROOKSTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56716-1808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-281-9100
Provider Business Practice Location Address Fax Number:
218-281-9189
Provider Enumeration Date:
02/08/2008

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: 363AM0700X , with the licence number:  10889 , 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: NA9481054162 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1154509479 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 30806 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 03M31AN . This is a "MN BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 30806 . This is a "ND BCBS" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 342440000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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