Provider Demographics
NPI:1043425044
Name:SODERLUND, RAYMOND CHARLES (PA)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:CHARLES
Last Name:SODERLUND
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3021 WILSON ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-2371
Mailing Address - Country:US
Mailing Address - Phone:612-782-8323
Mailing Address - Fax:
Practice Address - Street 1:2220 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1321
Practice Address - Country:US
Practice Address - Phone:612-371-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8847363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical