Provider Demographics
NPI:1407101538
Name:FOGAL, MITCHELL JOHN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:JOHN
Last Name:FOGAL
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:4200 DAHLBERG DR STE 300
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4841
Mailing Address - Country:US
Mailing Address - Phone:952-512-5637
Mailing Address - Fax:952-345-7707
Practice Address - Street 1:560 S MAPLE ST STE 200
Practice Address - Street 2:SUITE 200
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1757
Practice Address - Country:US
Practice Address - Phone:952-442-2163
Practice Address - Fax:952-442-5903
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-15
Last Update Date:2013-01-22
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Provider Licenses
StateLicense IDTaxonomies
MN11173363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant