Healthcare Provider Details

I. General information

NPI: 1497740054
Provider Name (Legal Business Name): ANASTAS C PROVATAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 17TH AVE E
ALEXANDRIA MN
56308-5273
US

IV. Provider business mailing address

610 30TH AVE W
ALEXANDRIA MN
56308-3426
US

V. Phone/Fax

Practice location:
  • Phone: 320-763-2707
  • Fax: 320-763-7883
Mailing address:
  • Phone: 320-763-5123
  • Fax: 320-763-7883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number105335
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number9500693
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: