Provider Demographics
NPI:1609417351
Name:PLAISANCE, CODY RAY (PA)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:RAY
Last Name:PLAISANCE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 S MAPLE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1757
Mailing Address - Country:US
Mailing Address - Phone:952-442-2163
Mailing Address - Fax:
Practice Address - Street 1:560 S MAPLE ST STE 200
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1757
Practice Address - Country:US
Practice Address - Phone:952-442-2163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13177363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant