Healthcare Provider Details

I. General information

NPI: 1285611673
Provider Name (Legal Business Name): AMY B SPOMER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 10/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6490 EXCELSIOR BLVD STE W01 PARK NICOLLET CLINIC - MEAD
ST LOUIS PARK MN
55426
US

IV. Provider business mailing address

6465 WAYZATA BLVD STE 315
ST LOUIS PARK MN
55426-1728
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-3248
  • Fax: 952-993-2810
Mailing address:
  • Phone: 952-993-7169
  • Fax: 952-993-0300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number38755
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: