Basic Information
| Provider Information | |||||||||
| NPI: | 1033150024 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KASTER | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | LEIGH NELLERMOE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NELLERMOE | ||||||||
| OtherFirstName: | ANDREA | ||||||||
| OtherMiddleName: | L. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2010 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581222484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012342000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 801 BROADWAY N | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581023641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012342000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 05/07/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 43686 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 13010 | ND | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0114429 | 01 | MN | MEDICA # | OTHER | 18314 | 05 | ND | MEDICAID | 504199600 | 05 | MN | MEDICAID | 0114428 | 01 | MN | MEDICA # | OTHER | 0114436 | 01 | MN | MEDICA # | OTHER | HP39698 | 01 | MN | HEALTHPARTNERS # | OTHER | 71G46KA | 01 | FM | MNBS # | OTHER | 71G47KA | 01 | MN | MNBS # | OTHER | 71G48KA | 01 | MN | MNBS # | OTHER | 137043 | 01 | MN | UCARE # | OTHER | 1935876 | 01 | MN | AMERICA'S PPO/ARAZ # | OTHER | 23613 | 01 | MN | NDBS # | OTHER | DA9041040454 | 01 | MN | PREFERRED ONE # | OTHER |