Provider Demographics
NPI:1801290614
Name:OSTERTAG, RILEY (PA-C)
Entity type:Individual
Prefix:
First Name:RILEY
Middle Name:
Last Name:OSTERTAG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:RILEY
Other - Middle Name:
Other - Last Name:BLYTHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2330 SIOUX TRL NW
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-9077
Mailing Address - Country:US
Mailing Address - Phone:952-496-6150
Mailing Address - Fax:952-233-4224
Practice Address - Street 1:2330 SIOUX TRL NW
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-9077
Practice Address - Country:US
Practice Address - Phone:952-496-6150
Practice Address - Fax:952-233-4224
Is Sole Proprietor?:No
Enumeration Date:2014-10-22
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11694363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical