Healthcare Provider Details

I. General information

NPI: 1497813190
Provider Name (Legal Business Name): MAPLEWOOD PODIATRY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 39TH AVENUE NE SUITE 250
ST. ANTHONY MN
55421
US

IV. Provider business mailing address

1940 GREELEY ST S SUITE 122
STILLWATER MN
55082-5097
US

V. Phone/Fax

Practice location:
  • Phone: 612-788-7274
  • Fax: 612-788-3408
Mailing address:
  • Phone: 651-439-5278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: ROSS NELSON
Title or Position: OWNER
Credential: DPM
Phone: 651-439-5278