Basic Information
Provider Information | |||||||||
NPI: | 1780607788 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOOVER | ||||||||
FirstName: | CASEY | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 515 12TH ST NE | ||||||||
Address2: |   | ||||||||
City: | DILWORTH | ||||||||
State: | MN | ||||||||
PostalCode: | 56529 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7013618025 | ||||||||
FaxNumber: | 7012344877 | ||||||||
Practice Location | |||||||||
Address1: | REJUV MEDICAL AESTHETIC CLINIC | ||||||||
Address2: | 3301 45TH ST S | ||||||||
City: | FARGO | ||||||||
State: | ND | ||||||||
PostalCode: | 58103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7013567546 | ||||||||
FaxNumber: | 8554518995 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/25/2006 | ||||||||
LastUpdateDate: | 08/28/2019 | ||||||||
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 | 363L00000X | R1717185 | MN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 19829 | 05 | ND |   | MEDICAID | 126677200 | 05 | MN |   | MEDICAID |