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General NPI Number Information
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NPI Number | 1508642232
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Entity Type | Organization
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Legal Business Name | DESWIL MEDICAL GROUP PLLC
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Dates
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Enumeration Date | 09/07/2023
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Last Update Date | 09/07/2023
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Provider Practice Location Address
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Address Line | 15815 FRANKLIN TRL SE STE 501
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City | PRIOR LAKE
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State | MN
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Zip | 55372-2076
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Country | US
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Telephone | 952-522-6344
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Fax |
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Provider Business Mailing Address
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Address Line | 15815 FRANKLIN TRL SE STE 501
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City | PRIOR LAKE
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State | MN
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Zip | 55372-2076
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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 | CEO
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Name | DR. NANA WILMOT-DESOUZA
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Credential | MD
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Telephone | 952-522-6344
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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