Healthcare Provider Details

I. General information

NPI: 1437659190
Provider Name (Legal Business Name): RILEY ODOM NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2018
Last Update Date: 03/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

559 CAPITOL BLVD
SAINT PAUL MN
55103-2101
US

IV. Provider business mailing address

2318 TAFT ST NE
MINNEAPOLIS MN
55418-4132
US

V. Phone/Fax

Practice location:
  • Phone: 651-232-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number5737
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: