Healthcare Provider Details

I. General information

NPI: 1689170805
Provider Name (Legal Business Name): PATRICK BARTHOLOMEW HERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 RIVERSIDE AVE
MINNEAPOLIS MN
55454-1450
US

IV. Provider business mailing address

1788 HUBBARD AVE
SAINT PAUL MN
55104-1134
US

V. Phone/Fax

Practice location:
  • Phone: 612-672-6000
  • Fax: 612-273-4098
Mailing address:
  • Phone: 612-710-6244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35136
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number35136
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: