Provider Demographics
NPI:1083894836
Name:VASCULAR SURGERY ASSOCIATES PA
Entity Type:Organization
Organization Name:VASCULAR SURGERY ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:STUART
Authorized Official - Last Name:WALVATNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:763-427-8547
Mailing Address - Street 1:11855 ULYSSES ST NE STE 220
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-4181
Mailing Address - Country:US
Mailing Address - Phone:763-427-8547
Mailing Address - Fax:763-576-5394
Practice Address - Street 1:11855 ULYSSES ST NE STE 220
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-4181
Practice Address - Country:US
Practice Address - Phone:763-427-8547
Practice Address - Fax:763-576-5394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN319672086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1778251Medicaid
MN020001359Medicare PIN