1336597079 NPI number — TREVOR J FOSSO

Table of content: TREVOR J FOSSO (NPI 1336597079)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336597079 NPI number — TREVOR J FOSSO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOSSO
Provider First Name:
TREVOR
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1336597079
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2180 TROOP DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SARTELL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56377-4563
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-258-3915
Provider Business Mailing Address Fax Number:
320-258-3917

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2180 TROOP DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SARTELL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56377-4563
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-258-3915
Provider Business Practice Location Address Fax Number:
320-258-3917
Provider Enumeration Date:
06/02/2016

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: 152W00000X , with the licence number:  MN3499 , 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: 1336597079 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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