Healthcare Provider Details

I. General information

NPI: 1417840067
Provider Name (Legal Business Name): PEDRO ENRIQUE PALOMO JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2025
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 RIVERSIDE AVE
MINNEAPOLIS MN
55454-1350
US

IV. Provider business mailing address

7445 OAK PARK VILLAGE DR APT 6
ST LOUIS PARK MN
55426-4143
US

V. Phone/Fax

Practice location:
  • Phone: 612-330-1000
  • Fax:
Mailing address:
  • Phone: 224-254-8757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
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: