Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 46784020 | WI |
Y | 207QS0010X | Family Doctor - Sports Medicine | 44664 | MN |
NPI | 1295701548 |
---|---|
Provider Name | Heather R Cichanowski |
First Address | Saint Paul, MN 55130-5302 |
Second Address | Saint Paul, MN 55130-5302 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/02/2006 |
Last Update Date | 22/05/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
177272400 | (05) | MN |
H63769 | (02) |