Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | D12133 | MN |
Y | 213EG0000X | General Practice | D12133 | MN |
NPI | 1003806027 |
---|---|
Provider Name | Michael Nelson |
First Address | Edina, MN 55436-2337 |
Second Address | Plymouth, MN 55441-3650 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/10/2005 |
Last Update Date | 08/07/2007 |