Healthcare Provider Details

I. General information

NPI: 1508833955
Provider Name (Legal Business Name): JON K. WOGENSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 05/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E NICOLLET BLVD
BURNSVILLE MN
55337-5714
US

IV. Provider business mailing address

201 E NICOLLET BLVD
BURNSVILLE MN
55337-5714
US

V. Phone/Fax

Practice location:
  • Phone: 952-892-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number17424
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: