MEDICARE: MAISA ALVES PEBBLES 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	363L00000X	Nurse Practitioner	575	MN

General Provider Information

NPI Number	:	1336117480
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAISA ALVES PEBBLES CNP

Provider Business Mailing Address
First Line	:	3300 OAKDALE AVE N
Second Line	:
City	:	ROBBINSDALE
State	:	MN
Zip	:	55422-2926
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9855 HOSPITAL DR STE 102A
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55369-4648
Country	:	US
Telephone Number	:	763-581-9220
Fax Number	:	763-581-9221

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

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	01/10/2025

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