Basic Information
Provider Information | |||||||||
NPI: | 1366559387 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HEIN | ||||||||
FirstName: | ELISSA | ||||||||
MiddleName: | S | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ST | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DUFFNEY | ||||||||
OtherFirstName: | ELISSA | ||||||||
OtherMiddleName: | S | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | ST | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4200 DAHLBERG DR | ||||||||
Address2: | SUITE 300 | ||||||||
City: | GOLDEN VALLEY | ||||||||
State: | MN | ||||||||
PostalCode: | 554224840 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9525125600 | ||||||||
FaxNumber: | 9525125651 | ||||||||
Practice Location | |||||||||
Address1: | 8540 QUADAY AVE NE | ||||||||
Address2: |   | ||||||||
City: | OTSEGO | ||||||||
State: | MN | ||||||||
PostalCode: | 553306522 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7634410298 | ||||||||
FaxNumber: | 7634410591 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/24/2006 | ||||||||
LastUpdateDate: | 10/17/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZS0410X |   |   | Y |   |   |   |   |
No ID Information.