Provider Demographics
NPI:1629612072
Name:MACPHERSON, IAN RODERICK (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:RODERICK
Last Name:MACPHERSON
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:937 CROMWELL AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1121
Mailing Address - Country:US
Mailing Address - Phone:651-890-2342
Mailing Address - Fax:
Practice Address - Street 1:4200 DAHLBERG DR STE 300
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4841
Practice Address - Country:US
Practice Address - Phone:952-512-5625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31602255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer