=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376306464
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARISE FAMILY MEDICAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2024
-----------------------------------------------------
Last Update Date | 03/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7447 EGAN DR STE 207
-----------------------------------------------------
City | SAVAGE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55378-3301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-381-5607
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15815 FRANKLIN TRL SE STE 501
-----------------------------------------------------
City | PRIOR LAKE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55372-2076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER
-----------------------------------------------------
Name | NANA WILMOT-DESOUZA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 512-773-4524
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------