1841094067 NPI number — DR. MATTILAN WINTER MARTIN CORREA LP

Table of content: DR. MATTILAN WINTER MARTIN CORREA LP (NPI 1841094067)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841094067 NPI number — DR. MATTILAN WINTER MARTIN CORREA LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN CORREA
Provider First Name:
MATTILAN
Provider Middle Name:
WINTER
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
LP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1841094067
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/04/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8721 PALMGREN AVE NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OTSEGO
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55330-4402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-619-6421
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
805 5TH ST SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASECA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56093-2003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-619-6421
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/04/2025

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  LP7142 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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