Provider Demographics
NPI:1730145764
Name:LONDON, ERVING WAYNE (CNP)
Entity type:Individual
Prefix:
First Name:ERVING
Middle Name:WAYNE
Last Name:LONDON
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 LAKE ROAD AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-1845
Mailing Address - Country:US
Mailing Address - Phone:763-588-7099
Mailing Address - Fax:763-522-2222
Practice Address - Street 1:4600 LAKE ROAD AVE STE 301
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-1845
Practice Address - Country:US
Practice Address - Phone:763-588-7099
Practice Address - Fax:763-522-2222
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0779645363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN894628100Medicaid
MN50002525Medicare ID - Type Unspecified
MN894628100Medicaid