Provider Demographics
NPI:1104823855
Name:MORTENSON, SANYA SHEREE (DC)
Entity Type:Individual
Prefix:
First Name:SANYA
Middle Name:SHEREE
Last Name:MORTENSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:SANYA
Other - Middle Name:SHEREE
Other - Last Name:MORTENSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:4680 SHERMAN DR NE
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5359
Mailing Address - Country:US
Mailing Address - Phone:218-444-8727
Mailing Address - Fax:
Practice Address - Street 1:403 AMERICA AVE NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3122
Practice Address - Country:US
Practice Address - Phone:218-444-8727
Practice Address - Fax:218-444-8546
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3546111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN770299OtherAMERICA'S PPO
MN292526500Medicaid
MN397L2MOOtherBLUE CROSS/BLUE SHIELD
MN292526500Medicaid
MN350003340Medicare PIN