Provider Demographics
NPI:1407524622
Name:BISTODEAU, MAGGIE LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:MAGGIE
Middle Name:LYNN
Last Name:BISTODEAU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MAGGIE
Other - Middle Name:LYNN
Other - Last Name:DONOVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:725 E FIGZEL CT STE 100
Mailing Address - Street 2:
Mailing Address - City:TEA
Mailing Address - State:SD
Mailing Address - Zip Code:57064-2276
Mailing Address - Country:US
Mailing Address - Phone:605-368-9899
Mailing Address - Fax:605-368-5089
Practice Address - Street 1:725 E FIGZEL CT STE 100
Practice Address - Street 2:
Practice Address - City:TEA
Practice Address - State:SD
Practice Address - Zip Code:57064-2276
Practice Address - Country:US
Practice Address - Phone:605-368-9899
Practice Address - Fax:605-368-5089
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1331363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1331OtherSDBMOE