Healthcare Provider Details

I. General information

NPI: 1942863451
Provider Name (Legal Business Name): JOHN CASNOVSKY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2019
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5775 WAYZATA BLVD STE 190
ST LOUIS PARK MN
55416-2627
US

IV. Provider business mailing address

5775 WAYZATA BLVD STE 400
ST LOUIS PARK MN
55416-1271
US

V. Phone/Fax

Practice location:
  • Phone: 952-541-1840
  • Fax: 952-543-6524
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number73386
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number73386
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: