Healthcare Provider Details

I. General information

NPI: 1265671671
Provider Name (Legal Business Name): JOSHUA SHANE MAXWELL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2009
Last Update Date: 05/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E 3RD ST
DULUTH MN
55805-1951
US

IV. Provider business mailing address

400 E 3RD ST ESSENTIA HEALTH DULUTH CLINIC
DULUTH MN
55805-1951
US

V. Phone/Fax

Practice location:
  • Phone: 218-786-8364
  • Fax:
Mailing address:
  • Phone: 218-786-8364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number56992
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number56992
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: