Provider Demographics
NPI:1154509479
Name:STAVETEIG, MINDY S (PA-C)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:S
Last Name:STAVETEIG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MINDY
Other - Middle Name:
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:400 S MINNESOTA STREET
Mailing Address - Street 2:
Mailing Address - City:CROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56716
Mailing Address - Country:US
Mailing Address - Phone:701-587-6000
Mailing Address - Fax:701-587-6009
Practice Address - Street 1:400 S MINNESOTA ST
Practice Address - Street 2:
Practice Address - City:CROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:56716-1808
Practice Address - Country:US
Practice Address - Phone:218-281-9100
Practice Address - Fax:218-281-9189
Is Sole Proprietor?:No
Enumeration Date:2008-02-08
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10889363AM0700X
NDPAC0385363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NA9481054162OtherPREFERRED ONE
1154509479OtherMEDICA
30806OtherTRICARE
MN03M31ANOtherMN BCBS
ND30806OtherND BCBS
MN342440000Medicaid
MN342440000Medicaid