Healthcare Provider Details

I. General information

NPI: 1043238843
Provider Name (Legal Business Name): MIDSOTA PLASTIC AND RECONSTRUCTIVE SURGEONS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 02/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 12TH ST N SUITE 100
SAINT CLOUD MN
56303-2255
US

IV. Provider business mailing address

3701 12TH ST N SUITE 100
SAINT CLOUD MN
56303-2255
US

V. Phone/Fax

Practice location:
  • Phone: 320-253-7257
  • Fax: 320-251-2938
Mailing address:
  • Phone: 320-253-7257
  • Fax: 320-251-2938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ENNIS H ARNSTON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 320-253-7257