Basic Information
| Provider Information | |||||||||
| NPI: | 1245793132 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHEATH | ||||||||
| FirstName: | SAMBATH | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4570 CTY. HWY. 61 | ||||||||
| Address2: | |||||||||
| City: | MOOSE LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557679401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2184854491 | ||||||||
| FaxNumber: | 2184854724 | ||||||||
| Practice Location | |||||||||
| Address1: | 707 LUNDORFF DR STE 1 | ||||||||
| Address2: | |||||||||
| City: | SANDSTONE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550725099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202452250 | ||||||||
| FaxNumber: | 3202452555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2019 | ||||||||
| LastUpdateDate: | 07/12/2019 | ||||||||
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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 | 363L00000X | 6513 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 6513 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 6513 | 01 | MN | CNP | OTHER |