Healthcare Provider Details

I. General information

NPI: 1932769502
Provider Name (Legal Business Name): MARK CANNON VALENTINE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E 28TH ST STE 401
MINNEAPOLIS MN
55407-3723
US

IV. Provider business mailing address

660 S EUCLID AVE OBSTETRICS AND GYNECOLOGY MAIL STOP 8064-37-1005
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 612-863-0200
  • Fax: 612-863-4689
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2019018211
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number82501
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: