Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111NN0400X | Neurology | 0007075 | CO |
Y | 111NN0400X | Neurology | 6545 | MN |
NPI | 1790114049 |
---|---|
Provider Name | Dr. Joshua Wallert |
First Address | Eagan, MN 55122-2357 |
Second Address | Eagan, MN 55122 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/11/2013 |
Last Update Date | 13/06/2019 |