Basic Information
| Provider Information | |||||||||
| NPI: | 1275707572 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YORGASON | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 10001 W INNOVATION DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889383838 | ||||||||
| FaxNumber: | 8889191083 | ||||||||
| Practice Location | |||||||||
| Address1: | 4365 PHEASANT RIDGE DR NE STE 106 | ||||||||
| Address2: | |||||||||
| City: | BLAINE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554494544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015028456 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2008 | ||||||||
| LastUpdateDate: | 07/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 63535711205 | UT | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 13346 | ND | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 56460 | MN | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 81070 | 05 | ND | MEDICAID | 56480 | 01 | MN | MN LICENSE | OTHER | 866460200 | 05 | MN | MEDICAID | FY0208579 | 01 | UT | DEA | OTHER |