Provider Demographics
NPI:1376502583
Name:STEPHAN, TIERZA MARIA (MD)
Entity Type:Individual
Prefix:MS
First Name:TIERZA
Middle Name:MARIA
Last Name:STEPHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:TIERZA
Other - Middle Name:MARIA
Other - Last Name:WIESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:800 E 28TH ST
Mailing Address - Street 2:MR 11326
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-3723
Mailing Address - Country:US
Mailing Address - Phone:612-262-1166
Mailing Address - Fax:
Practice Address - Street 1:800 E 28TH ST
Practice Address - Street 2:MR 11326
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3723
Practice Address - Country:US
Practice Address - Phone:612-863-7560
Practice Address - Fax:612-863-3809
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN35514207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN026818600Medicaid
110014318Medicare PIN
MN026818600Medicaid