Healthcare Provider Details

I. General information

NPI: 1053871194
Provider Name (Legal Business Name): MATTHEW MOLENAAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2019
Last Update Date: 08/19/2022
Certification Date: 08/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 6TH AVE N
SAINT CLOUD MN
56303-2736
US

IV. Provider business mailing address

1200 6TH AVE N
SAINT CLOUD MN
56303-2736
US

V. Phone/Fax

Practice location:
  • Phone: 320-251-2700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number71786
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: