Basic Information
| Provider Information | |||||||||
| NPI: | 1609824465 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAZE | ||||||||
| FirstName: | NOELLE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | R.N., M.A., C-A.N.P | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2925 CHICAGO AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554071321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122625000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8100 W 78TH ST | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554392516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529469777 | ||||||||
| FaxNumber: | 9529469888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R958958 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1012400 | 01 | MN | PREFERRED ONE | OTHER | 120003727 | 01 | MN | WEA | OTHER | 21R85MA | 01 | MN | BLUE CROSS/SHIELD | OTHER | 0401120 | 01 | MN | SELECT CARE | OTHER | 116764 | 01 | MN | UCARE | OTHER | 500005086 | 01 | MN | RAILROAD MEDICARE | OTHER | HP19245 | 01 | MN | HEALTHPARTNERS | OTHER | 23798 | 01 | MN | AMERICA'S PPO | OTHER | 0401120 | 01 | MN | MEDICA | OTHER | 108042 | 01 | MN | PATIENT CHOICE | OTHER | 947217700 | 05 | MN | MEDICAID |