Provider Demographics
NPI:1962432252
Name:GUTTORMSON, NANCY L (MD)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:L
Last Name:GUTTORMSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:L
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3400 W 66TH ST
Mailing Address - Street 2:SUITE 350
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2111
Mailing Address - Country:US
Mailing Address - Phone:952-832-0805
Mailing Address - Fax:952-832-5597
Practice Address - Street 1:303 E NICOLLET BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4522
Practice Address - Country:US
Practice Address - Phone:952-435-4140
Practice Address - Fax:952-435-4189
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30751208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN651363800Medicaid
MN020001857Medicare ID - Type UnspecifiedMEDICARE
MN651363800Medicaid