Provider Demographics
NPI:1417920190
Name:RUTTEN WASSON, SUSAN KRISTA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:KRISTA
Last Name:RUTTEN WASSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:KRISTA
Other - Last Name:RUTTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 W. NOKOMIS ST.
Mailing Address - Street 2:
Mailing Address - City:OSAKIS
Mailing Address - State:MN
Mailing Address - Zip Code:56360-8294
Mailing Address - Country:US
Mailing Address - Phone:320-859-2366
Mailing Address - Fax:320-859-5234
Practice Address - Street 1:200 W. NOKOMIS ST.
Practice Address - Street 2:
Practice Address - City:OSAKIS
Practice Address - State:MN
Practice Address - Zip Code:56360-8294
Practice Address - Country:US
Practice Address - Phone:320-859-2366
Practice Address - Fax:320-859-5234
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X
MN42061208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH02304Medicare UPIN