Individual
KEARNEY STAKES II
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1575 BEAM AVE, MAPLEWOOD, MN 55109-1126
(651) 232-7000
Mailing address
1575 BEAM AVE, MAPLEWOOD, MN 55109-1126
(651) 232-7000
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
9898
ND
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
13298
—
ND
Enumeration date
09/20/2006
Last updated
02/07/2011
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