Provider Demographics
NPI:1740309285
Name:FAUST, JONATHAN ANDREW (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ANDREW
Last Name:FAUST
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 1:14700 28TH AVE N
Mailing Address - Street 2:SUITE 20
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-4835
Mailing Address - Country:US
Mailing Address - Phone:763-559-3779
Mailing Address - Fax:
Practice Address - Street 1:14700 28TH AVE N
Practice Address - Street 2:SUITE 20
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-4835
Practice Address - Country:US
Practice Address - Phone:763-559-3779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN49717207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN371692000Medicaid
MN050002048Medicare PIN