Facts
- Status
- A
- Credential
- NP
- Type
- Individual
- Enumeration date
- 2006-06-23
- Last updated
- 2014-05-12
Licenses
- License MN
- R 147155-7
- License MN
- R 147155-7
Location
- Practice location
- 5200 FAIRVIEW BLVD
- City
- WYOMING MN
- Postal code
- 550928013
- Phone
- 651-982-7600
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.