Healthcare Provider Details

I. General information

NPI: 1689315814
Provider Name (Legal Business Name): MICHELE BUONOMO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2022
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18315 CASCADE DR STE 150
EDEN PRAIRIE MN
55347-1185
US

IV. Provider business mailing address

119 14TH ST NW STE 240
NEW BRIGHTON MN
55112-0007
US

V. Phone/Fax

Practice location:
  • Phone: 763-571-4000
  • Fax: 952-934-7488
Mailing address:
  • Phone: 763-502-2937
  • Fax: 651-631-1718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number82383
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: