Provider Demographics
NPI:1851066195
Name:COSSALTER, DALLAS TEAL (NP-C)
Entity Type:Individual
Prefix:
First Name:DALLAS
Middle Name:TEAL
Last Name:COSSALTER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 DEAN RD
Mailing Address - Street 2:
Mailing Address - City:ESKO
Mailing Address - State:MN
Mailing Address - Zip Code:55733-9729
Mailing Address - Country:US
Mailing Address - Phone:218-393-7344
Mailing Address - Fax:
Practice Address - Street 1:225 DEAN RD
Practice Address - Street 2:
Practice Address - City:ESKO
Practice Address - State:MN
Practice Address - Zip Code:55733-9729
Practice Address - Country:US
Practice Address - Phone:218-393-7344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8407363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner