Basic Information
| Provider Information | |||||||||
| NPI: | 1407101538 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOGAL | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4200 DAHLBERG DR STE 300 | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525125637 | ||||||||
| FaxNumber: | 9523457707 | ||||||||
| Practice Location | |||||||||
| Address1: | 560 S MAPLE ST STE 200 | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553871757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524422163 | ||||||||
| FaxNumber: | 9524425903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2012 | ||||||||
| LastUpdateDate: | 01/22/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 11173 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.