Healthcare Provider Details

I. General information

NPI: 1881736544
Provider Name (Legal Business Name): MINNESOTA ALLERGY & ASTHMA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 10/27/2024
Certification Date: 10/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6550 YORK AVE S STE 112
EDINA MN
55435-2332
US

IV. Provider business mailing address

6550 YORK AVE S STE 112
EDINA MN
55435-2332
US

V. Phone/Fax

Practice location:
  • Phone: 952-746-1854
  • Fax: 612-339-1854
Mailing address:
  • Phone: 952-746-1854
  • Fax: 527-461-8589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: BARBRA SIMMONS
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 517-936-8566