Provider Demographics
NPI:1194134981
Name:SCANDURRA, JOHN A
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:SCANDURRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:438 PORTLAND AVENUE
Mailing Address - Street 2:APT 8
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102
Mailing Address - Country:US
Mailing Address - Phone:612-819-0168
Mailing Address - Fax:
Practice Address - Street 1:438 PORTLAND AVE
Practice Address - Street 2:APT 8
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2290
Practice Address - Country:US
Practice Address - Phone:612-819-0168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN02510174M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174M00000XOther Service ProvidersVeterinarian