Healthcare Provider Details

I. General information

NPI: 1659345783
Provider Name (Legal Business Name): STEVEN B VANDONSELAAR PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 FRANCE AVE S STE 100
EDINA MN
55435-4738
US

IV. Provider business mailing address

4131 W LOOMIS RD STE 300
GREENFIELD WI
53221-2059
US

V. Phone/Fax

Practice location:
  • Phone: 763-537-6000
  • Fax: 763-537-6666
Mailing address:
  • Phone: 414-325-7246
  • Fax: 414-325-3770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9499
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: