Basic Information
| Provider Information | |||||||||
| NPI: | 1659345783 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDONSELAAR | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4131 W LOOMIS RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532212059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143257246 | ||||||||
| FaxNumber: | 4143253770 | ||||||||
| Practice Location | |||||||||
| Address1: | 7400 FRANCE AVE S STE 100 | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554354738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635376000 | ||||||||
| FaxNumber: | 7635376666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 363A00000X | 9499 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 213628700 | 05 | MN | MEDICAID |