Provider Demographics
NPI:1992113534
Name:DEPHILLIPO, NICHOLAS (ST, SA)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:DEPHILLIPO
Suffix:
Gender:M
Credentials:ST, SA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 DAHLBERG DR STE 300
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4841
Mailing Address - Country:US
Mailing Address - Phone:763-520-7870
Mailing Address - Fax:
Practice Address - Street 1:2700 VIKINGS CIR
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121
Practice Address - Country:US
Practice Address - Phone:952-456-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32362255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer