Provider Demographics
NPI:1760868053
Name:NEISEN, AUGUSTA RUTH (PA-C)
Entity Type:Individual
Prefix:
First Name:AUGUSTA
Middle Name:RUTH
Last Name:NEISEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:225 SMITH AVE N
Practice Address - Street 2:STE. 400
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2533
Practice Address - Country:US
Practice Address - Phone:651-290-0133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-10
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11879363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant