Basic Information
| Provider Information | |||||||||
| NPI: | 1669973962 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DACOSTA | ||||||||
| FirstName: | SELENA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3832 THOMAS AVE S | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554101232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2058764596 | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 PARK AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554151623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128733000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2018 | ||||||||
| LastUpdateDate: | 02/22/2018 | ||||||||
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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 | 363L00000X | 5532 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.