Provider Demographics
NPI:1013105907
Name:SANNEMAN, MAISY MONICA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MAISY
Middle Name:MONICA
Last Name:SANNEMAN
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 1:6525 FRANCE AVE. S.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435
Mailing Address - Country:US
Mailing Address - Phone:952-927-6501
Mailing Address - Fax:952-922-1623
Practice Address - Street 1:6525 FRANCE AVE. S.
Practice Address - Street 2:SUITE 200
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435
Practice Address - Country:US
Practice Address - Phone:952-927-6501
Practice Address - Fax:952-922-1623
Is Sole Proprietor?:No
Enumeration Date:2007-10-05
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10302363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant