1861449019 NPI number — MRS. SHAWN MARIE KRAUSE ROBERTS PT

Table of content: MRS. SHAWN MARIE KRAUSE ROBERTS PT (NPI 1861449019)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861449019 NPI number — MRS. SHAWN MARIE KRAUSE ROBERTS PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRAUSE ROBERTS
Provider First Name:
SHAWN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

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:
1861449019
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
430 5TH ST N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRECKENRIDGE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56520-1426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-641-7725
Provider Business Mailing Address Fax Number:
218-641-6625

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
430 5TH ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRECKENRIDGE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56520-1426
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-641-7725
Provider Business Practice Location Address Fax Number:
218-641-6625
Provider Enumeration Date:
05/30/2006

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: 225100000X , with the licence number:  6521 , 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: 23126 . This is a "NDBCBS FOR USE AT MN SITE" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 96570 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 057K9KR . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 101592300 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1458831 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1041486 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 64-04035 . This is a "MEDICA FOR MN SITE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 03N45KR . This is a "MNBCBS FOR USE AT ND SITE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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