MEDICARE: OSETOHAMEN ELIZABETH AGENE CNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	2020045045	MN

General Provider Information

NPI Number	:	1225673411
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OSETOHAMEN ELIZABETH AGENE CNP

Provider Business Mailing Address
First Line	:	5701 SHINGLE CREEK PKWY STE 115
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55430-2485
Country	:	US
Telephone Number	:	763-647-9868
Fax Number	:

Provider Business Practice Location Address
First Line	:	5701 SHINGLE CREEK PKWY STE 115
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55430-2485
Country	:	US
Telephone Number	:	763-208-5880
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/12/2019
Last Update Date	:	01/12/2021

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