Healthcare Provider Details

I. General information

NPI: 1770564932
Provider Name (Legal Business Name): BRIAN ERIC UNGLAUB ANP GNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 01/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6545 FRANCE AVE S STE 210
EDINA MN
55435-2281
US

IV. Provider business mailing address

2550 UNIVERSITY AVE W STE 110N
SAINT PAUL MN
55114-2001
US

V. Phone/Fax

Practice location:
  • Phone: 952-928-2900
  • Fax: 952-928-2944
Mailing address:
  • Phone: 651-602-5335
  • Fax: 651-665-9799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR 143562 9
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR143562-9
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: