Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224P00000X | Prosthetist |
NPI | 1063629368 |
---|---|
Provider Name | Peter Stasica |
First Address | Coon Rapids, MN 55433-7115 |
Second Address | Saint Paul, MN 55114-1839 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2007 |
Last Update Date | 08/07/2007 |