Provider Demographics
NPI:1336597079
Name:FOSSO, TREVOR J
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:J
Last Name:FOSSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2180 TROOP DR
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-4563
Mailing Address - Country:US
Mailing Address - Phone:320-258-3915
Mailing Address - Fax:320-258-3917
Practice Address - Street 1:2180 TROOP DR
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-4563
Practice Address - Country:US
Practice Address - Phone:320-258-3915
Practice Address - Fax:320-258-3917
Is Sole Proprietor?:No
Enumeration Date:2016-06-02
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN3499152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1336597079Medicaid