Basic Information
Provider Information
NPI: 1003005018
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: COULSON
FirstName: ANDREW
MiddleName: ROBERT
NamePrefix: DR.
NameSuffix:  
Credential: D.C.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 13800 83RD WAY N
Address2: SUITE 108
City: MAPLE GROVE
State: MN
PostalCode: 553697016
CountryCode: US
TelephoneNumber: 7634940828
FaxNumber: 7634940856
Practice Location
Address1: 13800 83RD WAY N
Address2: SUITE 108
City: MAPLE GROVE
State: MN
PostalCode: 553697016
CountryCode: US
TelephoneNumber: 7634940828
FaxNumber: 7634940856
Other Information
ProviderEnumerationDate: 10/16/2007
LastUpdateDate: 10/16/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
111N00000X4988MNY Chiropractic ProvidersChiropractor 

No ID Information.


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