Healthcare Provider Details

I. General information

NPI: 1194134981
Provider Name (Legal Business Name): JOHN A SCANDURRA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

438 PORTLAND AVE APT 8
SAINT PAUL MN
55102-2290
US

IV. Provider business mailing address

438 PORTLAND AVENUE APT 8
SAINT PAUL MN
55102
US

V. Phone/Fax

Practice location:
  • Phone: 612-819-0168
  • Fax:
Mailing address:
  • Phone: 612-819-0168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174M00000X
TaxonomyVeterinarian
License Number02510
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: