Basic Information
| Provider Information | |||||||||
| NPI: | 1275923971 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LABELLE | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 COMMERCE DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551254925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519685200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2620 EAGAN WOODS DR | ||||||||
| Address2: | |||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551211138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519685201 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2015 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 70082 | MN | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | 70082 | MN | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | 11709309-1205 | UT | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | 11709309-1205 | UT | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.