Provider Demographics
NPI:1316192511
Name:BAZUR-PERSING, LORETTA (NP)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:
Last Name:BAZUR-PERSING
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9900 BREN RD E
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-9664
Mailing Address - Country:US
Mailing Address - Phone:260-498-9252
Mailing Address - Fax:
Practice Address - Street 1:3025 N ANTHONY BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-2723
Practice Address - Country:US
Practice Address - Phone:260-740-3031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-02
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002754A363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200985990Medicaid
IN200985990Medicaid