Basic Information
| Provider Information | |||||||||
| NPI: | 1871245589 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOTASEK | ||||||||
| FirstName: | CASEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 328 10TH AVE S # 1 | ||||||||
| Address2: | |||||||||
| City: | SOUTH ST PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550752519 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 721 COMMERCE DR | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551259118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514244000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2022 | ||||||||
| LastUpdateDate: | 01/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.