Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207K00000X | Allergist & Immunologist | 28022 | MN |
NPI | 1104823335 |
---|---|
Provider Name | John Geoffrey Wahlstrom |
First Address | Saint Paul, MN 55116-1525 |
Second Address | Saint Paul, MN 55116-1525 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/07/2005 |
Last Update Date | 23/01/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D28714 | (02) | MN |