Provider Demographics
NPI:1316900590
Name:ENGEBRETSON, SALLY H (DO)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:H
Last Name:ENGEBRETSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:JEANNIE
Other - Last Name:HOLMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:9201 W BROADWAY AVE STE 601
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55445-1924
Mailing Address - Country:US
Mailing Address - Phone:763-587-7900
Mailing Address - Fax:763-587-7701
Practice Address - Street 1:15655 37TH AVE N STE 100
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55446-4003
Practice Address - Country:US
Practice Address - Phone:763-587-7900
Practice Address - Fax:763-587-7701
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43959207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN532434300Medicaid
MN110014472Medicare PIN