Provider Demographics
NPI:1508842105
Name:HUSEBY, AMY LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:HUSEBY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:LYNN
Other - Last Name:GOEBEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6465 WAYZATA BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6490 EXCELSIOR BLVD
Practice Address - Street 2:STE W200
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-4705
Practice Address - Country:US
Practice Address - Phone:952-993-3180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9774363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN876443300Medicaid