Graduated: 2022
NPI: 1669212395
Practice Locations (3)
12400 PORTLAND AVE, SUITE 180
BURNSVILLE, MN 553376805
1219 11TH AVE SW APT, SUITE 3
Forest Lake, MN 550251397
1219 11TH AVE SW, APT 3
FOREST LAKE, MN 550251397
Source: CMS National Downloadable File, September 2026.