Healthcare Provider Details

I. General information

NPI: 1578665105
Provider Name (Legal Business Name): KERRY MERVIN SOINEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 VETERANS DR
MINNEAPOLIS MN
55417-2309
US

IV. Provider business mailing address

172 6TH ST E APT. #2504
SAINT PAUL MN
55101-1993
US

V. Phone/Fax

Practice location:
  • Phone: 612-467-1854
  • Fax: 612-725-2227
Mailing address:
  • Phone: 651-230-9404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number9446
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: