Provider Demographics
NPI:1942851530
Name:RICHTER, JUSTIN M
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:M
Last Name:RICHTER
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 1:12321 LEVER ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-6643
Mailing Address - Country:US
Mailing Address - Phone:507-923-6095
Mailing Address - Fax:
Practice Address - Street 1:800 E 28TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3723
Practice Address - Country:US
Practice Address - Phone:612-863-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-25
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR2161060163WC0200X
MN2407367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine