Basic Information
| Provider Information | |||||||||
| NPI: | 1912982653 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SEYKORA | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | T. | ||||||||
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| Credential: | R.D., L.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 N STATE ST | ||||||||
| Address2: | WASECA MEDICAL CENTER - MAYO HEALTH SYSTEM | ||||||||
| City: | WASECA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5078351210 | ||||||||
| FaxNumber: | 5078374280 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 N STATE ST | ||||||||
| Address2: | WASECA MEDICAL CENTER - MAYO HEALTH SYSTEM | ||||||||
| City: | WASECA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5078351210 | ||||||||
| FaxNumber: | 5078374280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2005 | ||||||||
| LastUpdateDate: | 09/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 727534 | MN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 63-00264 | 01 | MN | MEDICA | OTHER |