Provider Demographics
NPI:1972974749
Name:SCHAEFBAUER, MACEY (PA-C)
Entity Type:Individual
Prefix:
First Name:MACEY
Middle Name:
Last Name:SCHAEFBAUER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MACEY
Other - Middle Name:
Other - Last Name:BENTLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1702 UNIVERSITY DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4940
Mailing Address - Country:US
Mailing Address - Phone:701-364-4222
Mailing Address - Fax:
Practice Address - Street 1:410 4TH ST NW
Practice Address - Street 2:
Practice Address - City:MAHNOMEN
Practice Address - State:MN
Practice Address - Zip Code:56557-4208
Practice Address - Country:US
Practice Address - Phone:218-935-2514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2356363A00000X
MN11978363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant