Basic Information
| Provider Information | |||||||||
| NPI: | 1750369765 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEUN | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8674 | ||||||||
| Address2: | MANKATO CLINIC LTD | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560028674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1421 PREMIER DR | ||||||||
| Address2: | MANKATO CLINIC @ WICKERSHAM CAMPUS | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 07/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 46561 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0117198 | 01 | MN | MEDICA | OTHER | 2242628 | 05 | IA | MEDICAID | NA2951040974 | 01 | MN | PREFERRED ONE | OTHER | 131456 | 01 | MN | UCARE | OTHER | 410849339 56001 C216 | 01 | CHAMPUS | OTHER | 2178704 | 01 | MN | AMERICAS PPO | OTHER | 252L9HE | 01 | MN | BCBS | OTHER | HP42266 | 01 | MN | HEALTH PARTNERS | OTHER | P00218990 | 01 | RR MEDICARE | OTHER | 892907600 | 05 | MN | MEDICAID |