Basic Information
Provider Information | |||||||||
NPI: | 1194723486 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RONGSTAD | ||||||||
FirstName: | AMY | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | F.N.P. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WELBERG | ||||||||
OtherFirstName: | AMY | ||||||||
OtherMiddleName: | J. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 824 N 11TH ST | ||||||||
Address2: |   | ||||||||
City: | MONTEVIDEO | ||||||||
State: | MN | ||||||||
PostalCode: | 562651629 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3202698877 | ||||||||
FaxNumber: | 3202698186 | ||||||||
Practice Location | |||||||||
Address1: | 824 N 11TH ST | ||||||||
Address2: |   | ||||||||
City: | MONTEVIDEO | ||||||||
State: | MN | ||||||||
PostalCode: | 562651629 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3202698877 | ||||||||
FaxNumber: | 3203208200 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2005 | ||||||||
LastUpdateDate: | 12/21/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/21/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R132176-2 | MN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 772668600 | 05 | MN |   | MEDICAID |