Basic Information
| Provider Information | |||||||||
| NPI: | 1104224666 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ATAY | ||||||||
| FirstName: | MEVHIBE | ||||||||
| MiddleName: | MERAL | ||||||||
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| Credential: | N.P., PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 S MAPLE ST | ||||||||
| Address2: | ATTN: MEDICAL STAFF OFFICE | ||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553871791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524422191 | ||||||||
| FaxNumber: | 9524428055 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 HUNDERTMARK RD STE 440 | ||||||||
| Address2: | |||||||||
| City: | CHASKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553181460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528564033 | ||||||||
| FaxNumber: | 9528564034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2014 | ||||||||
| LastUpdateDate: | 03/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 162274-6 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363L00000X | 2792 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1104224666 | 05 | MN | MEDICAID |