Basic Information
| Provider Information | |||||||||
| NPI: | 1881698801 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OSGOOD | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DANIELS | ||||||||
| OtherFirstName: | DEBORAH | ||||||||
| OtherMiddleName: | R | ||||||||
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| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2828 CHICAGO AVENUE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128791000 | ||||||||
| FaxNumber: | 6128799116 | ||||||||
| Practice Location | |||||||||
| Address1: | 11091 ULYSSES ST. NE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BLAINE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128791000 | ||||||||
| FaxNumber: | 6128790722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2005 | ||||||||
| LastUpdateDate: | 12/22/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 8942 | MN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 547077300 | 05 | MN | MEDICAID |