Organization
PARK NICOLLET
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SOFIYA TSUKERMAN (HTCP)
(763) 494-4686
Entity
Organization
Contact information
Practice address
9555 UPLAND LN N, MAPLE GROVE, MN 66369
(952) 993-1589
Mailing address
7102 OLIVE LANE NORTH, MAPLE GROVE, MN 55311
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
L 48617-4
MN
261QA1903X
Ambulatory Surgical Clinic/Center
L 48617-4
MN
Other
Enumeration date
08/31/2016
Last updated
08/31/2016
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