Provider Demographics
NPI:1447484159
Name:KOVANDA PLASTIC SURGERY, PLLC
Entity type:Organization
Organization Name:KOVANDA PLASTIC SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:KOVANDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:763-416-0676
Mailing Address - Street 1:9325 UPLAND LN N
Mailing Address - Street 2:SUITE 205
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4200
Mailing Address - Country:US
Mailing Address - Phone:763-416-0676
Mailing Address - Fax:763-416-0476
Practice Address - Street 1:4999 FRANCE AVE S STE 210
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55410-2168
Practice Address - Country:US
Practice Address - Phone:612-335-9032
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-08
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN416572086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1861501082OtherNPI INDIVIDUAL
MN852226000Medicaid
MN852226000Medicaid
MN240000189Medicare PIN