Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | 11934 | MN |
NPI | 1013507615 |
---|---|
Provider Name | Callen S Mouritsen |
First Address | Fergus Falls, MN 56537-1212 |
Second Address | Fergus Falls, MN 56537-3723 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/01/2021 |
Last Update Date | 19/01/2021 |