Healthcare Provider Details

I. General information

NPI: 1972974749
Provider Name (Legal Business Name): MACEY SCHAEFBAUER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MACEY BENTLEY PA-C

II. Dates (important events)

Enumeration Date: 10/19/2015
Last Update Date: 06/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 4TH ST NW
MAHNOMEN MN
56557-4208
US

IV. Provider business mailing address

1702 UNIVERSITY DR S
FARGO ND
58103-4940
US

V. Phone/Fax

Practice location:
  • Phone: 218-935-2514
  • Fax:
Mailing address:
  • Phone: 701-364-4222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2356
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11978
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: