Provider Demographics
NPI:1346799848
Name:SRSEN, REGINA ANN
Entity Type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:ANN
Last Name:SRSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2897 FOREST RDG
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-1112
Mailing Address - Country:US
Mailing Address - Phone:952-457-6602
Mailing Address - Fax:
Practice Address - Street 1:2897 FOREST RDG
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-1112
Practice Address - Country:US
Practice Address - Phone:952-457-6602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-25
Last Update Date:2016-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM#K153389332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNK153389OtherPRESCRIPTION FDA MEDICAL DEVICE #K153389 / TREATMENT PLAN CPT-97026