Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 59333 | MN |
NPI | 1003250655 |
---|---|
Provider Name | Erik Bostrom |
First Address | Aitkin, MN 56431-1865 |
Second Address | Aitkin, MN 56431-1865 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/04/2013 |
Last Update Date | 23/10/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1003250655 | (05) | MN |