Basic Information
| Provider Information | |||||||||
| NPI: | 1962977728 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | YADETTA | ||||||||
| FirstName: | DALESO | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2550 UNIVERSITY AVE W STE 110N | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551142001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516025311 | ||||||||
| FaxNumber: | 6512226786 | ||||||||
| Practice Location | |||||||||
| Address1: | 11850 BLACKFOOT ST NW STE 100 | ||||||||
| Address2: | |||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7637122100 | ||||||||
| FaxNumber: | 7637122190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2018 | ||||||||
| LastUpdateDate: | 10/09/2018 | ||||||||
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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 | 363A00000X | 12817 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.