Basic Information
| Provider Information | |||||||||
| NPI: | 1982201174 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RASMUSSEN | ||||||||
| FirstName: | DANE | ||||||||
| MiddleName: | JEFFREY | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1997 SLOAN PL STE 17 | ||||||||
| Address2: | |||||||||
| City: | MAPLEWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551172051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517726251 | ||||||||
| FaxNumber: | 6512249661 | ||||||||
| Practice Location | |||||||||
| Address1: | 1997 SLOAN PL STE 17 | ||||||||
| Address2: | |||||||||
| City: | MAPLEWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551172051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517726251 | ||||||||
| FaxNumber: | 6512249661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2020 | ||||||||
| LastUpdateDate: | 10/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 13464 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.