Facts
- Status
- A
- Credential
- MD
- Type
- Individual
- Enumeration date
- 2018-05-16
- Last updated
- 2022-01-21
Licenses
- License WI
- 21418
- License MN
- 68890
Location
- Practice location
- 640 JACKSON ST
- City
- SAINT PAUL MN
- Postal code
- 551012502
- Phone
- 651-254-3456
Medicare
- PECOS
- A PECOS enrollment row matches this NPI.
LEIE
The OIG NPI list is not in this build yet. Confirm on OIG's search.
Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.