Basic Information
Provider Information | |||||||||
NPI: | 1992033922 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PYAE | ||||||||
FirstName: | NYAN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2854 HIGHWAY 55 STE 130 | ||||||||
Address2: |   | ||||||||
City: | EAGAN | ||||||||
State: | MN | ||||||||
PostalCode: | 551211447 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512244930 | ||||||||
FaxNumber: | 6518423391 | ||||||||
Practice Location | |||||||||
Address1: | 1997 SLOAN PL STE 17 | ||||||||
Address2: |   | ||||||||
City: | MAPLEWOOD | ||||||||
State: | MN | ||||||||
PostalCode: | 551172051 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5177262516 | ||||||||
FaxNumber: | 6512249661 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/02/2009 | ||||||||
LastUpdateDate: | 04/04/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/04/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 11661 | ND | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | PT 11661 | ND | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RN0300X | 5447 | MN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207RN0300X | 53447 | MN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.