Provider Demographics
NPI:1629389341
Name:BEVAN, MICHAEL STEPHEN (DPM)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STEPHEN
Last Name:BEVAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7770 DELL RD
Mailing Address - Street 2:STE 140
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-9316
Mailing Address - Country:US
Mailing Address - Phone:952-934-9360
Mailing Address - Fax:952-975-0118
Practice Address - Street 1:825 NICOLLET MALL STE 517
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402
Practice Address - Country:US
Practice Address - Phone:612-788-8778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN919213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1629389341Medicaid