Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0120X | Pediatric Surgery | 30222 | MN |
NPI | 1013978568 |
---|---|
Provider Name | David G Rustad |
First Address | Minneapolis, MN 55404-4289 |
Second Address | Edina, MN 55435-5417 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/03/2006 |
Last Update Date | 08/08/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
837782100 | (05) | MN |
A96122 | (02) | MN |