1619386083 NPI number — MR. RICHARD JOHN MASTENBROOK CNP

Table of content: MR. RICHARD JOHN MASTENBROOK CNP (NPI 1619386083)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619386083 NPI number — MR. RICHARD JOHN MASTENBROOK CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MASTENBROOK
Provider First Name:
RICHARD
Provider Middle Name:
JOHN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CNP
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:
1619386083
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1700 UNIVERSITY AVE W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55104-3727
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-232-2002
Provider Business Mailing Address Fax Number:
651-326-9635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11725 STINSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHISAGO CITY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55013-9542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-257-8850
Provider Business Practice Location Address Fax Number:
651-257-8852
Provider Enumeration Date:
08/10/2014

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: 363L00000X , with the licence number:  AG0714121 , 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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