Provider Demographics
NPI:1104128701
Name:LOVDAHL, SHAYNA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:SHAYNA
Middle Name:MARIE
Last Name:LOVDAHL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 N 11TH ST
Mailing Address - Street 2:
Mailing Address - City:MONTEVIDEO
Mailing Address - State:MN
Mailing Address - Zip Code:56265-1629
Mailing Address - Country:US
Mailing Address - Phone:320-269-8877
Mailing Address - Fax:320-321-8200
Practice Address - Street 1:824 N 11TH ST
Practice Address - Street 2:
Practice Address - City:MONTEVIDEO
Practice Address - State:MN
Practice Address - Zip Code:56265-1629
Practice Address - Country:US
Practice Address - Phone:320-321-8422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-02
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10859363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant