Healthcare Provider Details

I. General information

NPI: 1922234780
Provider Name (Legal Business Name): DR. KARL VANCE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2009
Last Update Date: 10/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1356 LUSITANA ST FL 7
HONOLULU HI
96813-2421
US

IV. Provider business mailing address

2 CARLSON PKWY N STE 240
PLYMOUTH MN
55447-4485
US

V. Phone/Fax

Practice location:
  • Phone: 808-586-2910
  • Fax:
Mailing address:
  • Phone: 763-746-0030
  • Fax: 763-367-7977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number56445
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number56445
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: