Provider Demographics
NPI:1265516439
Name:STASKO, ANDREW JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:JOHN
Last Name:STASKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 2ND AVE N
Mailing Address - Street 2:
Mailing Address - City:WAHPETON
Mailing Address - State:ND
Mailing Address - Zip Code:58075-4528
Mailing Address - Country:US
Mailing Address - Phone:701-642-7000
Mailing Address - Fax:701-642-7055
Practice Address - Street 1:2101 ELM ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2417
Practice Address - Country:US
Practice Address - Phone:701-239-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0057295208600000X
ND10708208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND14398Medicaid
1052517OtherPREFERREDONE
NC30107OtherND BCBS
MD511208700Medicaid
HP84016OtherHEALTHPARTNERS
MN248487100Medicaid
PENDINGOtherMN BCBS
1052517OtherPREFERREDONE
MD511208700Medicaid