Basic Information
| Provider Information | |||||||||
| NPI: | 1205365707 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIRON | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | GLAESS | ||||||||
| OtherFirstName: | STACEY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15250 HOMESTEAD AVE N | ||||||||
| Address2: | |||||||||
| City: | HUGO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550389408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6129409064 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5200 FAIRVIEW BLVD | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550928013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519827000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2017 | ||||||||
| LastUpdateDate: | 08/16/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 10660 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 10660 | 01 | MN | MINNESOTA BOARD OF PHYSICAL THERAPY | OTHER |