Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NS0005X | Chiropractic Sports Physician | 2841 | MN |
NPI | 1316149297 |
---|---|
Provider Name | Dr. Robert Mattson |
First Address | Ely, MN 55731-1428 |
Second Address | Ely, MN 55731-1428 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/06/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U20587 | (02) | MN |