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General NPI Number Information
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NPI Number | 1114332301
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Entity Type | Organization
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Legal Business Name | SP PLASTIC SURGERY, LLC
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Dates
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Enumeration Date | 06/25/2014
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Last Update Date | 11/07/2022
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Provider Practice Location Address
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Address Line | 15450 HIGHWAY 7 STE 225
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City | MINNETONKA
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State | MN
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Zip | 55345-3522
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Country | US
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Telephone | 763-999-4170
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Fax | 763-951-0941
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Provider Business Mailing Address
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Address Line | 15450 HIGHWAY 7 STE 225
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City | MINNETONKA
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State | MN
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Zip | 55345-3522
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Country | US
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Telephone | 763-999-4170
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Fax | 763-951-0941
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Authorized Official
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Title or Position | PRESIDENT
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Name | STEPHANIE LEE PENG
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Credential | MD
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Telephone | 763-999-4170
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | 57866
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License Number State | MN
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