Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 34012342 | OH |
Y | 207QS0010X | Family Doctor - Sports Medicine | 62865 | MN |
NPI | 1154767366 |
---|---|
Provider Name | David A Supik |
First Address | Minneapolis, MN 55455-4800 |
Second Address | Minneapolis, MN 55455-4800 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/05/2013 |
Last Update Date | 06/09/2017 |