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NPI Code Detail

MEDICARE: TANYA S ERNTSON OD

MEDICARE: TANYA S ERNTSON OD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1152W00000XOptometrist2927MN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1700864279
Entity Type Code : Individual
Provider Name (Legal Business Name) : TANYA S ERNTSON OD
Provider Business Mailing Address
First Line : 4455 HIGHWAY 169 N
Second Line :
City : PLYMOUTH
State : MN
Zip : 55442-2897
Country : US
Telephone Number : 763-559-7358
Fax Number : 763-559-2167
Provider Business Practice Location Address
First Line : 4455 HIGHWAY 169 N
Second Line :
City : PLYMOUTH
State : MN
Zip : 55442-2897
Country : US
Telephone Number : 763-559-7358
Fax Number : 763-559-2167
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/05/2006
Last Update Date : 11/17/2020

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