Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208D00000X | General Practice Physician | TRAINING PERMIT | SD |
NPI | 1033436670 |
---|---|
Provider Name | Ryan Michael Hegg |
First Address | Rochester, MN 55905-0001 |
Second Address | Rochester, MN 55905-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/04/2010 |
Last Update Date | 22/09/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
ENROLLED | (05) | IA |
ENROLLED | (05) | MN |