Basic Information
| Provider Information | |||||||||
| NPI: | 1164603783 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAAGEN | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 86 SDS 12 2901 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554862901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519685050 | ||||||||
| FaxNumber: | 6519685900 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 SMITH AVE N STE 370 | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551022383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519685250 | ||||||||
| FaxNumber: | 6519685901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2007 | ||||||||
| LastUpdateDate: | 11/18/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 10359 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AM0700X | PAC0567 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.