Provider Demographics
NPI:1306847314
Name:RIERSON, GRETCHEN M (MD)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:M
Last Name:RIERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3955 PARKLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5655
Mailing Address - Country:US
Mailing Address - Phone:952-831-4454
Mailing Address - Fax:
Practice Address - Street 1:3955 PARKLAWN AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55435-5655
Practice Address - Country:US
Practice Address - Phone:952-831-4454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45102208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN609883500Medicaid
MN609883500Medicaid