Provider Demographics
NPI:1164491676
Name:WALKINGTON-STAUBER, MAYA M (GNP)
Entity Type:Individual
Prefix:
First Name:MAYA
Middle Name:M
Last Name:WALKINGTON-STAUBER
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16555 KLAMATH TER
Mailing Address - Street 2:16555 KLAMATH TERRACE
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-8425
Mailing Address - Country:US
Mailing Address - Phone:612-859-1138
Mailing Address - Fax:
Practice Address - Street 1:3400 W 66TH ST
Practice Address - Street 2:#290
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2111
Practice Address - Country:US
Practice Address - Phone:952-914-1969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1053357363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNR85985Medicare UPIN