Provider Demographics
NPI:1467052092
Name:HOISTAD, BRAXTEN
Entity Type:Individual
Prefix:
First Name:BRAXTEN
Middle Name:
Last Name:HOISTAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13043 EUROPA TRAIL WAY N UNIT H
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:MN
Mailing Address - Zip Code:55038-4649
Mailing Address - Country:US
Mailing Address - Phone:701-899-0727
Mailing Address - Fax:
Practice Address - Street 1:1011 MEADOWLANDS DR
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55127-2339
Practice Address - Country:US
Practice Address - Phone:612-445-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-01
Last Update Date:2020-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other