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General NPI Number Information
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NPI Number | 1508562240
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Entity Type | Organization
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Legal Business Name | PAIN SPECIALIST OF MINNESOTA
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Dates
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Enumeration Date | 02/03/2023
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Last Update Date | 01/22/2025
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Provider Practice Location Address
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Address Line | 5810 EXCELSIOR BLVD
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City | ST LOUIS PARK
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State | MN
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Zip | 55416-2830
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Country | US
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Telephone | 612-235-6008
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Fax | 612-235-6003
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Provider Business Mailing Address
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Address Line | 5810 EXCELSIOR BLVD
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City | ST LOUIS PARK
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State | MN
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Zip | 55416-2830
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Country | US
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Telephone | 612-235-6008
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Fax | 612-235-6003
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Authorized Official
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Title or Position | CEO
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Name | MARK STOCK
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Credential |
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Telephone | 651-238-8580
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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