Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LC0200X | Nurse Practitioner - Critical Care Medicine | 5737 | MN |
NPI | 1437659190 |
---|---|
Provider Name | Riley Odom |
First Address | Minneapolis, MN 55418-4132 |
Second Address | Saint Paul, MN 55103-2101 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/02/2018 |
Last Update Date | 22/03/2018 |