Provider Demographics
NPI:1861556805
Name:AHLGREN, MARK (C PED)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:AHLGREN
Suffix:
Gender:M
Credentials:C PED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2047 117TH LN NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-5456
Mailing Address - Country:US
Mailing Address - Phone:763-757-8086
Mailing Address - Fax:763-862-4797
Practice Address - Street 1:2047 117TH LN NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-5456
Practice Address - Country:US
Practice Address - Phone:763-757-8086
Practice Address - Fax:763-862-4797
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist