Provider Demographics
NPI:1972515427
Name:WALVATNE, CRAIG STUART (MD)
Entity type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:STUART
Last Name:WALVATNE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3887 COON RAPIDS BLVD NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2518
Mailing Address - Country:US
Mailing Address - Phone:763-427-8547
Mailing Address - Fax:763-576-5394
Practice Address - Street 1:11855 ULYSSES ST NE
Practice Address - Street 2:220
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-3947
Practice Address - Country:US
Practice Address - Phone:763-427-8547
Practice Address - Fax:763-576-5394
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI27345-020208600000X, 2086S0102X
MN31967208600000X, 2086S0102X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN476753500Medicaid
MN1778251Medicaid
MNHSZ009OtherMEDICARE GRP B
MN301T6WAOtherBCBS
MN240206Medicare Oscar/Certification
MN301T6WAOtherBCBS