Healthcare Provider Details

I. General information

NPI: 1992628689
Provider Name (Legal Business Name): NICK HERVATIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2026
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

991 SIBLEY MEMORIAL HWY STE 207
LILYDALE MN
55118-5116
US

IV. Provider business mailing address

991 SIBLEY MEMORIAL HWY STE 207
LILYDALE MN
55118-5116
US

V. Phone/Fax

Practice location:
  • Phone: 952-443-4600
  • Fax: 952-443-4604
Mailing address:
  • Phone: 952-443-4600
  • Fax: 952-443-4604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: