Healthcare Provider Details

I. General information

NPI: 1467419473
Provider Name (Legal Business Name): MARY C HOMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15075 CIMARRON AVE
ROSEMOUNT MN
55068-1635
US

IV. Provider business mailing address

15075 CIMARRON AVE
ROSEMOUNT MN
55068-1635
US

V. Phone/Fax

Practice location:
  • Phone: 651-322-8800
  • Fax:
Mailing address:
  • Phone: 651-322-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30458
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: