Healthcare Provider Details

I. General information

NPI: 1104803881
Provider Name (Legal Business Name): CRAIG STIBAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 10/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 PARK NICOLLET BLVD
ST LOUIS PARK MN
55416-2527
US

IV. Provider business mailing address

6465 WAYZATA BLVD STE 315
MINNEAPOLIS MN
55426-1728
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-7750
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number602
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: