Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | D14292 | MN |
NPI | 1073013025 |
---|---|
Provider Name | Krista Primley |
First Address | Minneapolis, MN 55455-0357 |
Second Address | Minneapolis, MN 55455 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/02/2018 |
Last Update Date | 29/07/2019 |