Healthcare Provider Details

I. General information

NPI: 1013797216
Provider Name (Legal Business Name): OLUWASEGUN PAUL DAVID DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2023
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5775 WAYZATA BLVD FL 2
ST LOUIS PARK MN
55416-1222
US

IV. Provider business mailing address

9084 FARMSTEAD AVE
MONTICELLO MN
55362-8461
US

V. Phone/Fax

Practice location:
  • Phone: 952-525-4500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10648
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: