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| Profile Details |
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| Licensee Public Information |
| Licensure Designated Address: |
1601 Golf Course Rd |
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Grand Rapids, MN 55744 |
| Web Site: |
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Birth Year: |
1988 |
| E-mail: |
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Gender: |
Male |
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| License Information |
| License
Number: |
67373 |
License
Type: |
Physician and Surgeon |
| Expiration
Date: |
12/31/2021 |
Grant Date: |
05/07/2020 |
| License Status: |
Active |
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| Disciplinary
Action: |
No |
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Corrective Action:
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No
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Disciplinary Actions by Other States (Reported to the Board since July 1, 2013):
No
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Public - Other:
No
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Education
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| Medical
School: |
UNIVERSITY OF MINNESOTA MEDICAL SCHOOL MINNEAPOLIS USA |
Degree: |
M.D. |
| Location: |
Minneapolis, MN USA |
Date: |
05/06/2016
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| Practice Locations (Self-Reported Information) |
| Primary Location: |
Grand Itasca Clinic and Hospital |
Secondary Location: |
Ridgeview Medical Center |
| 1601 Golf Course Rd |
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| Grand Rapids, MN 55744 |
Waconia, MN 55387 |
| Phone: |
Unknown |
Phone: |
Unknown |
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| Post-Graduate Training (Self-Reported Information, Not Verified by Board of Medical Practice) |
| Program | Specialty | Start Date | End Date | Completed |
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Area of Specialty (Certified by American
Board of Medical Specialties or American Osteopathic Specialty Boards; Refer to
the Note at the End of this Page)
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| Source | Board | Certification / Sub-Certification |
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Criminal Convictions (Self-Reported Information)
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| Type | Crime Description | Conviction Date | Court of Jurisdiction | Sentence/Comment |
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| Disclaimer |
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The Minnesota Board of Medical Practice provides this information as a service to the public. The Board relies upon information provided by licensees to be true and accurate. Information that is self-reported by the provider has not been verified by the Board. The Board makes no warranty or guarantee concerning the accuracy or completeness of the self-reported information contained on this web page. Neither the Minnesota Board of Medical Practice, nor any source of information on this web page, shall be responsible for any errors or omissions, or for the use of this information.
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| Primary Source Verification |
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The license information in this web page has been designed and implemented to meet primary source verification requirements of the Joint Commission accredited hospitals and the National Committee for Quality Assurance (NCQA) certified managed care organizations, and it can be used as the primary source verification.
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| Note on 'Area of Specialty' |
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Specialty board certification information was obtained directly from American Board of Medical Specialties (ABMS),
www.abms.org, or American Board of Osteopathic Medical Specialties (AOA), www.aoa-net.org, as a written direct verification, quarterly update, or from the official ABMS or AOA primary source verification website. Minnesota's Physician Profile contains specialty certifications only from ABMS and AOA, because they are universally recognized and easily verifiable. Other organizations certify and endorse specialization with their own standards and procedures. You may wish to ask your physician about such certifications if he or she does not list one of the specialties from the ABMS or AOA.
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| Maintenance of Certification (MOC) |
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MOC is an ABMS program of lifelong learning and requires physicians to self-assess their competency. Further information can be found at
www.abms.org. The American Osteopathic Association also has a continuous lifelong process "Osteopathic Continuous Certification" or OCC. Further information is available at www.osteopathic.org.
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| Criminal Conviction |
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Minnesota Statute 214.072 (a)(1) requires the Board to post licensee’s "conviction of a felony or gross misdemeanor occurring on or after July 1, 2013, in any state or jurisdiction."
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| IMLC (Interstate Medical Licensure Compact) |
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License Types with the designation (IMLC) denote that this Minnesota Physician & Surgeon License was issued though the IMLC process. Please refer to https://imlcc.org for more information about the Interstate Medical Licensure Compact.
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