Provider Demographics
NPI:1619386083
Name:MASTENBROOK, RICHARD JOHN (CNP)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:JOHN
Last Name:MASTENBROOK
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
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Mailing Address - Street 1:1700 UNIVERSITY AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3727
Mailing Address - Country:US
Mailing Address - Phone:516-232-2002
Mailing Address - Fax:651-326-9635
Practice Address - Street 1:11725 STINSON AVE
Practice Address - Street 2:
Practice Address - City:CHISAGO CITY
Practice Address - State:MN
Practice Address - Zip Code:55013-9542
Practice Address - Country:US
Practice Address - Phone:651-257-8850
Practice Address - Fax:651-257-8852
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-10
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNAG0714121363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner