Facts
- Status
- A
- Credential
- MD
- Type
- Individual
- Enumeration date
- 2005-11-03
- Last updated
- 2023-03-07
Licenses
- License MN
- 38835
- License MN
- 38835
- License MN
- 38835
Location
- Practice location
- 1200 SIXTH AVE N, CENTRACARE CLINIC
- City
- ST CLOUD MN
- Postal code
- 563032735
- Phone
- 320-252-5131
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.