Basic Information
Provider Information | |||||||||
NPI: | 1780837641 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STUTZ | ||||||||
FirstName: | REBECCA | ||||||||
MiddleName: | SUE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1702 UNIVERSITY DR S | ||||||||
Address2: |   | ||||||||
City: | FARGO | ||||||||
State: | ND | ||||||||
PostalCode: | 581034940 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7013644222 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1027 WASHINGTON AVE | ||||||||
Address2: |   | ||||||||
City: | DETROIT LAKES | ||||||||
State: | MN | ||||||||
PostalCode: | 56501 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2188475611 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/23/2008 | ||||||||
LastUpdateDate: | 05/22/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 750 | ND | N |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   | 363A00000X | 12383 | MN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.