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General NPI Number Information
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NPI Number | 1043317274
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Entity Type | Organization
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Legal Business Name | AFFILIATED FOOT AND ANKLE
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2805 CAMPUS DR STE 225
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City | PLYMOUTH
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State | MN
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Zip | 55441-2678
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Country | US
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Telephone | 763-383-8808
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Fax | 763-383-6033
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Provider Business Mailing Address
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Address Line | 2805 CAMPUS DR #225
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City | PLYMOUTH
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State | MN
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Zip | 55441
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Country | US
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Telephone | 763-383-8808
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Fax | 763-383-6033
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JOHN W CHEESEBRO
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Credential | DPM
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Telephone | 763-383-8808
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 366
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License Number State | MN
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