Basic Information
| Provider Information | |||||||||
| NPI: | 1548821622 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEISLER | ||||||||
| FirstName: | RYAN | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15700 37TH AVE N STE 150 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554463675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519685201 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15700 37TH AVE N STE 150 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554463675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519685201 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2019 | ||||||||
| LastUpdateDate: | 06/27/2019 | ||||||||
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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 | 363L00000X | 6659 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | F06192736 | 01 | MN | AANP | OTHER |