Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | 29871 | MN |
NPI | 1124060272 |
---|---|
Provider Name | Matthew Mesnik |
First Address | Golden Valley, MN 55422-3304 |
Second Address | Blaine, MN 55449-5056 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
E80506 | (02) | MN |