Basic Information
| Provider Information | |||||||||
| NPI: | 1497740054 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PROVATAS | ||||||||
| FirstName: | ANASTAS | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3605 MAYFAIR AVE | ||||||||
| Address2: | |||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557462935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182623441 | ||||||||
| FaxNumber: | 2183626908 | ||||||||
| Practice Location | |||||||||
| Address1: | 3605 MAYFAIR AVE | ||||||||
| Address2: | |||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557462935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182623441 | ||||||||
| FaxNumber: | 2183626908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 04/05/2011 | ||||||||
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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 | 207RH0003X | 9500693 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | 105335 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
No ID Information.