Healthcare Provider Details

I. General information

NPI: 1932569035
Provider Name (Legal Business Name): DAVID MAKONDE OGATO CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2016
Last Update Date: 11/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5325 W 74TH ST
EDINA MN
55439-2231
US

IV. Provider business mailing address

1359 KNOLL DR
SHAKOPEE MN
55379-4624
US

V. Phone/Fax

Practice location:
  • Phone: 612-271-1181
  • Fax: 651-571-0018
Mailing address:
  • Phone: 651-354-6602
  • Fax: 952-835-3895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCNP 4260
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: