Provider Demographics
NPI:1891706263
Name:DETTMER, ABBY M (DO)
Entity Type:Individual
Prefix:
First Name:ABBY
Middle Name:M
Last Name:DETTMER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 LOOKOUT DR
Mailing Address - Street 2:
Mailing Address - City:NORTH MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56003-2503
Mailing Address - Country:US
Mailing Address - Phone:507-625-1811
Mailing Address - Fax:
Practice Address - Street 1:1575 LOOKOUT DR
Practice Address - Street 2:
Practice Address - City:NORTH MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56003-2503
Practice Address - Country:US
Practice Address - Phone:507-625-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-7613207Q00000X
MN50395207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0478677Medicaid
I64980Medicare UPIN