1417920190 NPI number — DR. SUSAN KRISTA RUTTEN WASSON M.D.

Table of content: DR. SUSAN KRISTA RUTTEN WASSON M.D. (NPI 1417920190)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417920190 NPI number — DR. SUSAN KRISTA RUTTEN WASSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUTTEN WASSON
Provider First Name:
SUSAN
Provider Middle Name:
KRISTA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RUTTEN
Provider Other First Name:
SUSAN
Provider Other Middle Name:
KRISTA
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1417920190
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 W. NOKOMIS ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OSAKIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56360-8294
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-859-2366
Provider Business Mailing Address Fax Number:
320-859-5234

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 W. NOKOMIS ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OSAKIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56360-8294
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-859-2366
Provider Business Practice Location Address Fax Number:
320-859-5234
Provider Enumeration Date:
02/10/2006

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: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 42061 , 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)





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