Basic Information
| Provider Information | |||||||||
| NPI: | 1356792808 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAYO CLINIC HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5755 W 136TH ST | ||||||||
| Address2: | |||||||||
| City: | SAVAGE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 501 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | WASECA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5078351210 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2016 | ||||||||
| LastUpdateDate: | 06/27/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ONDUSO | ||||||||
| AuthorizedOfficialFirstName: | JUDITH | ||||||||
| AuthorizedOfficialMiddleName: | MORAA | ||||||||
| AuthorizedOfficialTitleorPosition: | FAMILY NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 6513669109 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DNP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.