Basic Information
| Provider Information | |||||||||
| NPI: | 1497739247 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAUCIERI | ||||||||
| FirstName: | KARA | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DAHLEN | ||||||||
| OtherFirstName: | KARA | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 320 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CROSBY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564411645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2185467000 | ||||||||
| FaxNumber: | 2185454456 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CROSBY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564411645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2185467000 | ||||||||
| FaxNumber: | 2185454456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 11/19/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 38856 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080006801 | 01 | MEDICARE | OTHER | NS1141016489 | 01 | PREFERRED ONE | OTHER | 0116180 | 01 | MEDICA | OTHER | 112865C750 | 01 | UCARE | OTHER | 50Q23MA | 01 | BCBS | OTHER | 7884035 | 01 | AETNA | OTHER | 779799 | 01 | AMERICAS PPO | OTHER | E007 | 01 | TRICARE | OTHER | 246823900 | 05 | MN | MEDICAID | 080122966 | 01 | RR MEDICARE | OTHER | HP26005 | 01 | HEALTHPARTNERS | OTHER |