Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NR0200X | Radiology | 2731 | MN |
Y | 213ER0200X | Radiology | 2731 | MN |
NPI | 1790975324 |
---|---|
Provider Name | Dr. Timothy John Mick |
First Address | Saint Paul, MN 55117-3504 |
Second Address | Saint Paul, MN 55117-3504 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/07/2007 |
Last Update Date | 30/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U30633 | (02) | MN |