Healthcare Provider Details

I. General information

NPI: 1912015561
Provider Name (Legal Business Name): AMY ANNE DONATELLI LASSIG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 PHALEN BLVD
SAINT PAUL MN
55130-5302
US

IV. Provider business mailing address

8170 33RD AVE S # MS 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 952-967-7977
  • Fax: 651-254-8558
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number49555
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number4301078065
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: