Healthcare Provider Details

I. General information

NPI: 1861502593
Provider Name (Legal Business Name): ST PAUL PLASTIC SURGERY LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

393 N DUNLAP ST 832
ST PAUL MN
55104
US

IV. Provider business mailing address

393 N DUNLAP ST 832
ST PAUL MN
55104
US

V. Phone/Fax

Practice location:
  • Phone: 651-646-2717
  • Fax: 651-646-5144
Mailing address:
  • Phone: 651-646-2717
  • Fax: 651-646-5144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: PATTI J LEMAX
Title or Position: OFFICE MANAGER
Credential:
Phone: 651-646-2717