| NPI Number | 1164836334 |
| Provider Name | Drew James Christianson |
| Credential | |
| Specialization | |
| Medical School Name | |
| Graduation Year | |
| Gender | |
| Entity Type | Individual |
| PAC ID by PECOS | |
| Professional Enrollment ID | |
| Enumeration Date | 06/16/2014 |
| Last Update Date | 02/08/2022 |
| Business Practice address |
12936 63RD AVE N, Maple Grove, 55369-6001 Minnesota View on Google Map |
| Business Practice phone | 763-559-3400 |
| Business Practice fax | |
| Mailing address |
12936 63RD AVE N, Maple Grove, 55369-6001 Minnesota View on Google Map |
| Other phone | 763-559-3400 |
| Other fax | |
| Email Address | shannonfig@domain.com Reval Email Address |
Practices in Maple Grove
Maple Grove, Minnesota
| Field Name | Field Value |
|---|---|
| NPI | 1164836334 |
| 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. | |
| Entity Type | Individual |
Code describing the type of health care provider that is being assigned an NPI. Codes are:
|
|
| Is Sole Proprietor | N |
Indicate whether provider is a sole proprietor.
|
|
| Provider Last Name (Legal Name) | Christianson |
| The last name of the provider (if an individual). If the provider is an individual, this is the legal name. This name must match the name on file with the Social Security Administration (SSA). In addition, the date of birth must match that on file with SSA. (First and last names are required for initial applications.) The First, Middle, Last and Credential(s) fields allow the following special characters: ampersand, apostrophe, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters. | |
| Provider First Name | Drew |
| The first name of the provider, if the provider is an individual. | |
| Provider Credential Text | MDT |
| The abbreviations for professional degrees or credentials used or held by the provider, if the provider is an individual. Examples are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations will not be verified by NPS. | |
| Provider First Line Business Mailing Address | 12936 63RD AVE N |
| The first line mailing address of the provider being identified. This data element may contain the same information as ''Provider first line location address''. | |
| Provider Business Mailing Address City Name | Maple Grove |
| The City name in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address City name''. | |
| Provider Business Mailing Address State Name | Minnesota |
| The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address State name''. | |
| Provider Business Mailing Address Postal Code | 55369-6001 |
| The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as ''Provider location address postal code''. | |
| Provider Business Mailing Address Country Code | US |
| The country code in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address country code''. | |
| Provider Business Mailing Address Telephone Number | 763-559-3400 |
| The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as ''Provider location address telephone number''. | |
| Provider First Line Business Practice Location Address | 12936 63RD AVE N |
| The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. | |
| Provider Business Practice Location Address City Name | Maple Grove |
| The city name in the location address of the provider being identified. | |
| Provider Business Practice Location Address State Name | Minnesota |
| The State or Province name in the location address of the provider being identified. | |
| Provider Business Practice Location Address Postal Code | 55369-6001 |
| The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. | |
| Provider Business Practice Location Address Country Code | US |
| The country code in the location address of the provider being identified. | |
| Provider Business Practice Location Address Telephone Number | 763-559-3400 |
| The telephone number associated with the location address of the provider being identified. | |
| Provider Enumeration Date | 06/16/2014 |
| The date the provider was assigned a unique identifier (assigned an NPI). | |
| Last Update Date | 02/08/2022 |
| The date that a record was last updated or changed. | |
| Healthcare Provider Taxonomy Code #1 | 125K00000X |
| The Health Care Provider Taxonomy code is a unique alphanumeric code, ten characters in length. The code set is structured into three distinct "Levels" including Provider Type, Classification, and Area of Specialization. | |
| Healthcare Provider Taxonomy 1 | An Advanced Practice Dental Therapist is:<br/>(1) A dental therapist who has completed additional training beyond basic dental therapy education and provides dental services in accordance with state advanced practice dental therapist laws or statutes; or<br/>(2) A dental hygienist with a graduate degree in advanced dental therapy prepared for independent and interdependent decision making and direct accountability for clinical judgment across the dental health care continuum.<br/>The individual has been authorized by the relevant state board or a tribal entity to provide services under the remote supervision of a dentist. The functions of the advanced practice dental therapist vary based on the needs of the dentist, the educational preparation of the advanced practice dental therapist and state dental practice acts and regulations. |
| Healthcare Provider Taxonomy #1 | |
| Provider License Number 1 | DT45 |
| Certain taxonomy selections will require you to enter your license number and the state where the license was issued. Select Foreign Country in the state drop down box if the license was issued outside of United States. The License Number field allows the following special characters: ampersand, apostrophe, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters. DO NOT report the Social Security Number (SSN), IRS Individual Taxpayer Identification Number (ITIN) in this section. | |
| Provider License Number State Code 1 | MN |
| Provider License Number State Code #1 | |
| Healthcare Provider Primary Taxonomy Switch 1 | Y |
Primary Taxonomy:
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|
| Healthcare Provider Taxonomy Code #2 | 125J00000X |
| The Health Care Provider Taxonomy code is a unique alphanumeric code, ten characters in length. The code set is structured into three distinct "Levels" including Provider Type, Classification, and Area of Specialization. | |
| Healthcare Provider Taxonomy 2 | A Dental Therapist is an individual who has completed an accredited or non-accredited dental therapy program and who has been authorized by the relevant state board or a tribal entity to provide services within the scope of their practice under the supervision of a dentist. Functions that may be delegated to the dental therapist vary based on the needs of the dentist, the educational preparation of the dental therapist and state dental practice acts and regulations. |
| Healthcare Provider Taxonomy #2 | |
| Provider License Number 2 | DT45 |
| Certain taxonomy selections will require you to enter your license number and the state where the license was issued. Select Foreign Country in the state drop down box if the license was issued outside of United States. The License Number field allows the following special characters: ampersand, apostrophe, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters. DO NOT report the Social Security Number (SSN), IRS Individual Taxpayer Identification Number (ITIN) in this section. | |
| Provider License Number State Code 2 | MN |
| Provider License Number State Code #2 | |
| Healthcare Provider Primary Taxonomy Switch 2 | N |
Primary Taxonomy:
|
