Provider Demographics
NPI:1053411157
Name:VERTIZ-HACKETT, ROSALYNN (PA)
Entity type:Individual
Prefix:
First Name:ROSALYNN
Middle Name:
Last Name:VERTIZ-HACKETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S- PO BOX 1309
Mailing Address - Street 2:MAIL STOP 21110Q
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:651-653-2100
Mailing Address - Fax:651-653-2125
Practice Address - Street 1:1430 HIGHWAY 96 E
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3653
Practice Address - Country:US
Practice Address - Phone:651-653-2100
Practice Address - Fax:651-653-2125
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04432363A00000X
MN11431363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00N29FMedicare PIN