Healthcare Provider Details

I. General information

NPI: 1255951190
Provider Name (Legal Business Name): MINNESOTA NEONATAL SPECIALISTS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2020
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9875 HOSPITAL DR
MAPLE GROVE MN
55369-4648
US

IV. Provider business mailing address

9325 UPLAND LN N STE 360
MAPLE GROVE MN
55369-4463
US

V. Phone/Fax

Practice location:
  • Phone: 612-322-6903
  • Fax:
Mailing address:
  • Phone: 612-322-6903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: RICHARD MAKI
Title or Position: BUSINESS MANAGER
Credential:
Phone: 612-322-6905