Basic Information
| Provider Information | |||||||||
| NPI: | 1366426413 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PINE | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6465 WAYZATA BLVD | ||||||||
| Address2: | STE 315 | ||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554261728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529936450 | ||||||||
| FaxNumber: | 9529930300 | ||||||||
| Practice Location | |||||||||
| Address1: | 17821 HWY 7 | ||||||||
| Address2: | PARK NICOLLET CLINIC-MINNETONKA | ||||||||
| City: | MINNETONKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553454186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529932900 | ||||||||
| FaxNumber: | 9529932910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 11/02/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 21253 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.