Healthcare Provider Details

I. General information

NPI: 1669426532
Provider Name (Legal Business Name): CLOVER G SCHULTZ-TIEDEKEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 8TH ST NW
AUSTIN MN
55912-2473
US

IV. Provider business mailing address

1906 8TH ST NW STE A
AUSTIN MN
55912-2478
US

V. Phone/Fax

Practice location:
  • Phone: 507-434-6982
  • Fax: 507-434-6983
Mailing address:
  • Phone: 507-434-6982
  • Fax: 507-434-6983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9159
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: