Healthcare Provider Details

I. General information

NPI: 1770099103
Provider Name (Legal Business Name): ASHTON MAE MAKWANA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2017
Last Update Date: 12/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 CURVE CREST BLVD W STE 104
STILLWATER MN
55082-6181
US

IV. Provider business mailing address

5803 NEAL AVE N
OAK PARK HEIGHTS MN
55082-2177
US

V. Phone/Fax

Practice location:
  • Phone: 651-439-8807
  • Fax: 651-439-0232
Mailing address:
  • Phone: 651-439-8807
  • Fax: 651-439-0232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12555
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: