Facts
- Status
- A
- Credential
- DO
- Type
- Individual
- Enumeration date
- 2016-06-29
- Last updated
- 2021-02-08
Licenses
- License MN
- 68212
- License WI
- 74059-21
- License MI
- 5101022642
Location
- Practice location
- 407 E 3RD ST
- City
- DULUTH MN
- Postal code
- 558051950
- Phone
- 218-786-8364
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
Search this city from the state hub for other records in the public registry.
Removal request
Public data from NPPES and CMS. Not a credentialing determination.