Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 18257 | MN |
Y | 208600000X | Surgeon | 18257 | MN |
NPI | 1023092996 |
---|---|
Provider Name | Don W Wennberg |
First Address | Brainerd, MN 56401-4529 |
Second Address | Brainerd, MN 56401-4529 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/12/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D49052 | (02) | MN |