Basic Information
| Provider Information | |||||||||
| NPI: | 1699041848 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | WARD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WARD | ||||||||
| OtherFirstName: | KATHERINE | ||||||||
| OtherMiddleName: | ANNE | ||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8170 33RD AVE S # MS 21110Q | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554254516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6515238500 | ||||||||
| FaxNumber: | 9528538727 | ||||||||
| Practice Location | |||||||||
| Address1: | 3930 NORTHWOODS DR | ||||||||
| Address2: | |||||||||
| City: | ARDEN HILLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551126963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6515238500 | ||||||||
| FaxNumber: | 6515238584 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2012 | ||||||||
| LastUpdateDate: | 04/02/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 58487 | MN | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.