1265516439 NPI number — DR. ANDREW JOHN STASKO M.D.

Table of content: MS. DYMPHNA RODRIGUEZ RN (NPI 1265637169)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265516439 NPI number — DR. ANDREW JOHN STASKO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STASKO
Provider First Name:
ANDREW
Provider Middle Name:
JOHN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265516439
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
332 2ND AVE N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAHPETON
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58075-4528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-642-7000
Provider Business Mailing Address Fax Number:
701-642-7055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2101 ELM ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58102-2417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-239-3700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/24/2006

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: 208600000X , with the licence number:  D0057295 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 10708 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 14398 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1052517 . This is a "PREFERREDONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 30107 . This is a "ND BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 511208700 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: HP84016 . This is a "HEALTHPARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 248487100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: PENDING . This is a "MN BCBS" identifier . This identifiers is of the category "OTHER".




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