Provider Demographics
NPI:1407363112
Name:RADWAN, WALEED
Entity Type:Individual
Prefix:
First Name:WALEED
Middle Name:
Last Name:RADWAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14540 FLORISSANT PATH
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-4535
Mailing Address - Country:US
Mailing Address - Phone:612-708-7586
Mailing Address - Fax:
Practice Address - Street 1:14540 FLORISSANT PATH
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-4535
Practice Address - Country:US
Practice Address - Phone:612-708-7586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNBC693555171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171WH0202XOther Service ProvidersContractorHome ModificationsGroup - Single Specialty