Basic Information
| Provider Information | |||||||||
| NPI: | 1972974749 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCHAEFBAUER | ||||||||
| FirstName: | MACEY | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BENTLEY | ||||||||
| OtherFirstName: | MACEY | ||||||||
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| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1702 UNIVERSITY DR S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581034940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013644222 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 410 4TH ST NW | ||||||||
| Address2: | |||||||||
| City: | MAHNOMEN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565574208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2189352514 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2015 | ||||||||
| LastUpdateDate: | 06/27/2016 | ||||||||
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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 | 363A00000X | 2356 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 11978 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.