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General NPI Number Information
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NPI Number | 1174715361
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Entity Type | Individual
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Provider Name | COREY NATHANIEL FETT
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Gender | Male
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Dates
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Enumeration Date | 08/13/2007
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Last Update Date | 08/13/2007
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Provider Practice Location Address
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Address Line | 600 W 98TH ST #390A
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City | BLOOMINGTON
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State | MN
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Zip | 55420-4773
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Country | US
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Telephone | 952-885-6200
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Fax |
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Provider Business Mailing Address
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Address Line | 1679 COUNTRYSIDE DR
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City | SHAKOPEE
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State | MN
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Zip | 55379-4527
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 7937
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License Number State | MN
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