Healthcare Provider Details

I. General information

NPI: 1043449663
Provider Name (Legal Business Name): PADMA PALLAVI YARRAPUREDDY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2009
Last Update Date: 09/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 HIGHWAY 96 E
WHITE BEAR LAKE MN
55110
US

IV. Provider business mailing address

8170 33RD AVE MS 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 651-653-2100
  • Fax: 651-653-2125
Mailing address:
  • Phone: 651-653-2100
  • Fax: 651-653-2125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number55008
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: