Provider Demographics
NPI:1033178538
Name:DOMEYER, EVAN L (DO)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:L
Last Name:DOMEYER
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:MR 10809
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-4813
Mailing Address - Fax:612-262-4194
Practice Address - Street 1:3960 COON RAPIDS BLVD NW
Practice Address - Street 2:100
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2569
Practice Address - Country:US
Practice Address - Phone:763-236-9400
Practice Address - Fax:763-236-9423
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2020-11-10
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Provider Licenses
StateLicense IDTaxonomies
MN44533207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN315794600Medicaid