Healthcare Provider Details

I. General information

NPI: 1821815697
Provider Name (Legal Business Name): GREATER MINNESOTA ALLERGY AND ASTHMA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 NORTHWAY DR STE 101
SAINT CLOUD MN
56303-1262
US

IV. Provider business mailing address

1511 NORTHWAY DR STE 101
SAINT CLOUD MN
56303-1262
US

V. Phone/Fax

Practice location:
  • Phone: 320-654-8266
  • Fax: 320-654-8481
Mailing address:
  • Phone: 320-654-8266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MINTO K PORTER
Title or Position: OWNER
Credential: MD
Phone: 320-654-8266