Healthcare Provider Details

I. General information

NPI: 1902303670
Provider Name (Legal Business Name): SCOTT ALLEN HOFSTADTER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2018
Last Update Date: 04/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 DEER RIDGE RD
ELY MN
55731-0593
US

IV. Provider business mailing address

PO BOX 593
ELY MN
55731-0593
US

V. Phone/Fax

Practice location:
  • Phone: 612-805-8270
  • Fax: 612-805-8270
Mailing address:
  • Phone: 612-805-8270
  • Fax: 612-805-8270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA445
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: