Healthcare Provider Details

I. General information

NPI: 1518675149
Provider Name (Legal Business Name): JAY SATHER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 11/14/2022
Certification Date: 11/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 EXCELSIOR BLVD STE 202
ST LOUIS PARK MN
55416-2734
US

IV. Provider business mailing address

12815 ARBOR LAKES PKWY N
MAPLE GROVE MN
55369-7060
US

V. Phone/Fax

Practice location:
  • Phone: 952-548-9340
  • Fax: 952-548-9350
Mailing address:
  • Phone: 763-257-2917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number31153
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: