Basic Information
| Provider Information | |||||||||
| NPI: | 1770876187 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOIVISTO | ||||||||
| FirstName: | DUANE | ||||||||
| MiddleName: | OLIVER | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2532 1ST AVE S | ||||||||
| Address2: | #104 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554044368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128252905 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11400 JULIANNE AVE N | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550829436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514263300 | ||||||||
| FaxNumber: | 6514260419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2011 | ||||||||
| LastUpdateDate: | 05/18/2011 | ||||||||
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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 | 164W00000X | L 63350-3 | MN | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.