Healthcare Provider Details

I. General information

NPI: 1447484159
Provider Name (Legal Business Name): KOVANDA PLASTIC SURGERY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2009
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4999 FRANCE AVE S STE 210
EDINA MN
55410-2168
US

IV. Provider business mailing address

9325 UPLAND LN N SUITE 205
MAPLE GROVE MN
55369-4200
US

V. Phone/Fax

Practice location:
  • Phone: 612-335-9032
  • Fax:
Mailing address:
  • Phone: 763-416-0676
  • Fax: 763-416-0476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number41657
License Number StateMN

VIII. Authorized Official

Name: CHRISTOPHER JOHN KOVANDA
Title or Position: SOLE MEMBER
Credential: M.D.
Phone: 763-416-0676