Basic Information
| Provider Information | |||||||||
| NPI: | 1518399294 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STASSEN | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | LOU | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 9201 W BROADWAY AVE | ||||||||
| Address2: | SUITE 601 | ||||||||
| City: | BROOKLYN PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554451923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635877974 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3366 OAKDALE AVE N | ||||||||
| Address2: | SUITE 551 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554222948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635877737 | ||||||||
| FaxNumber: | 7635877069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2013 | ||||||||
| LastUpdateDate: | 08/05/2013 | ||||||||
| 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 | 363LG0600X | AG0713052 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.