Provider Demographics
NPI:1770271967
Name:LOSASSO, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:LOSASSO
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 1:1005 GRAMSIE RD APT 357
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-3140
Mailing Address - Country:US
Mailing Address - Phone:651-357-5158
Mailing Address - Fax:
Practice Address - Street 1:2 PINE TREE DR
Practice Address - Street 2:
Practice Address - City:ARDEN HILLS
Practice Address - State:MN
Practice Address - Zip Code:55112-3754
Practice Address - Country:US
Practice Address - Phone:651-635-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-26
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant