Healthcare Provider Details

I. General information

NPI: 1225151418
Provider Name (Legal Business Name): WOODBURY PLASTIC SURGERY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 12/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 BIELENBERG DR STE 250
WOODBURY MN
55125-1414
US

IV. Provider business mailing address

604 BIELENBERG DR STE 250
WOODBURY MN
55125-1414
US

V. Phone/Fax

Practice location:
  • Phone: 651-730-4100
  • Fax: 651-730-4107
Mailing address:
  • Phone: 651-730-4100
  • Fax: 651-730-4107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number47379
License Number StateMN

VIII. Authorized Official

Name: MS. MALAY L THAO
Title or Position: OFFICE MANAGER
Credential:
Phone: 651-730-4100