Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 38741 | MN |
Y | 208600000X | Surgeon | 38741 | MN |
NPI | 1003869637 |
---|---|
Provider Name | Dr. Mario Potvin |
First Address | Saint Paul, MN 55105-1122 |
Second Address | Thief River Falls, MN 56701-2700 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2006 |
Last Update Date | 04/03/2021 |