Basic Information
| Provider Information | |||||||||
| NPI: | 1932183274 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARNSWORTH | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | GORDON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 818 | ||||||||
| Address2: | |||||||||
| City: | KAMUELA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967430818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8088855900 | ||||||||
| FaxNumber: | 8088856900 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 S 5TH ST | ||||||||
| Address2: | |||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560014588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073044071 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 02/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084F0202X | 29686 | MN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Forensic Psychiatry | 2084P0800X | 29686 | MN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 133085300 | 05 | MN | MEDICAID |