Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | 47318 | MN |
N | 2080P0203X | Pediatric Critical Care Doctor | 49021 | WI |
NPI | 1134189970 |
---|---|
Provider Name | Polo Chen |
First Address | Maple Grove, MN 55369 |
Second Address | Coon Rapids, MN 55433 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/03/2006 |
Last Update Date | 24/08/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
I50440 | (02) |