Individual
MARK K THALACKER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CNP
Contact information
Practice address
1875 WOODWINDS DR, SUITE 130, WOODBURY, MN 55125-2298
(651) 232-0500
Mailing address
1875 WOODWINDS DR, SUITE 130, WOODBURY, MN 55125-2298
(651) 232-0500
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
R096321-5
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
815725100
—
MN
Enumeration date
02/01/2006
Last updated
02/26/2024
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