Basic Information
| Provider Information | |||||||||
| NPI: | 1235517673 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEISBROD | ||||||||
| FirstName: | BREANNA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 501 STATE ST N | ||||||||
| Address2: | |||||||||
| City: | WASECA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560932811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5078351210 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 501 STATE ST N | ||||||||
| Address2: | |||||||||
| City: | WASECA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5078351210 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2015 | ||||||||
| LastUpdateDate: | 09/18/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 1697001 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163WX0200X | 127626 | KS | N | Nursing Service Providers | Registered Nurse | Oncology | 364SA2200X | 76387 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health | 363LF0000X | 6943 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.