Healthcare Provider Details

I. General information

NPI: 1992394944
Provider Name (Legal Business Name): SKIN PROFESSIONALS WEST, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2021
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

582 CHERRY DR
WACONIA MN
55387-4578
US

IV. Provider business mailing address

582 CHERRY DR
WACONIA MN
55387-4578
US

V. Phone/Fax

Practice location:
  • Phone: 952-395-6850
  • Fax: 952-395-6870
Mailing address:
  • Phone: 952-395-6850
  • Fax: 952-395-6870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State

VIII. Authorized Official

Name: KAMRUZ DARABI
Title or Position: OWNER
Credential: MD
Phone: 952-395-6850