Basic Information
| Provider Information | |||||||||
| NPI: | 1700064110 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PESAVENTO | ||||||||
| FirstName: | MONICA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 319 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540222452 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 319 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540222452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154256701 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2008 | ||||||||
| LastUpdateDate: | 02/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME98845 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 51672 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 35314200 | 05 | WI | MEDICAID |