Healthcare Provider Details

I. General information

NPI: 1740285220
Provider Name (Legal Business Name): ROSS NELSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2599 WHITE BEAR AVE N
SAINT PAUL MN
55109-5171
US

IV. Provider business mailing address

2520 WHITE BEAR AVE N SUITE A
MAPLEWOOD MN
55109-5136
US

V. Phone/Fax

Practice location:
  • Phone: 651-770-3891
  • Fax: 651-748-3117
Mailing address:
  • Phone: 651-770-3891
  • Fax: 651-748-3117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number468
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number468
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: