Healthcare Provider Details

I. General information

NPI: 1992113534
Provider Name (Legal Business Name): NICHOLAS DEPHILLIPO ST, SA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 06/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 VIKINGS CIR
EAGAN MN
55121
US

IV. Provider business mailing address

4200 DAHLBERG DR STE 300
GOLDEN VALLEY MN
55422-4841
US

V. Phone/Fax

Practice location:
  • Phone: 952-456-7600
  • Fax:
Mailing address:
  • Phone: 763-520-7870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number3236
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: