Individual
MR. CHARLES GLEN MICKELSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
C.PED.
Contact information
Practice address
423 12TH AVE. NORTH, SOUTH ST. PAUL,, MN 55075-1915
(651) 291-7000
Mailing address
423 12TH AVE. NORTH, SOUTH ST. PAUL,, MN 55075-1915
(651) 291-7000
Taxonomy
Speciality
Code
Description
License number
State
224L00000X
Pedorthist
Primary
—
MN
Other
Enumeration date
06/24/2010
Last updated
11/09/2010
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