Provider Demographics
NPI:1124453899
Name:WELO, CLAIRE RUSTAD (PA-C)
Entity type:Individual
Prefix:
First Name:CLAIRE
Middle Name:RUSTAD
Last Name:WELO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CLAIRE
Other - Middle Name:MARIE
Other - Last Name:RUSTAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:1710 E SHORE DR
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-4210
Mailing Address - Country:US
Mailing Address - Phone:612-723-8793
Mailing Address - Fax:
Practice Address - Street 1:576 BIELENBERG DR STE 250
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1739
Practice Address - Country:US
Practice Address - Phone:866-821-0281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-12
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3258133V00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered