Healthcare Provider Details

I. General information

NPI: 1104128701
Provider Name (Legal Business Name): SHAYNA MARIE LOVDAHL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2010
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 N 11TH ST
MONTEVIDEO MN
56265-1629
US

IV. Provider business mailing address

824 N 11TH ST
MONTEVIDEO MN
56265-1629
US

V. Phone/Fax

Practice location:
  • Phone: 320-321-8422
  • Fax:
Mailing address:
  • Phone: 320-269-8877
  • Fax: 320-321-8200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10859
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: