Healthcare Provider Details

I. General information

NPI: 1043425044
Provider Name (Legal Business Name): RAYMOND CHARLES SODERLUND PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 RIVERSIDE AVE
MINNEAPOLIS MN
55454-1321
US

IV. Provider business mailing address

3021 WILSON ST NE
MINNEAPOLIS MN
55418-2371
US

V. Phone/Fax

Practice location:
  • Phone: 612-371-1600
  • Fax:
Mailing address:
  • Phone: 612-782-8323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number8847
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: