Healthcare Provider Details

I. General information

NPI: 1457437741
Provider Name (Legal Business Name): SIGNE DYSKEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2006
Last Update Date: 07/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 PARK GLEN RD SUITE 360
ST LOUIS PARK MN
55416-4871
US

IV. Provider business mailing address

4500 PARK GLEN RD SUITE 360
ST LOUIS PARK MN
55416-4871
US

V. Phone/Fax

Practice location:
  • Phone: 612-822-2111
  • Fax:
Mailing address:
  • Phone: 612-822-2111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number28125
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number28125
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: