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General NPI Number Information
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NPI Number | 1023089547
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Entity Type | Individual
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Provider Name | ETHAN CONROY PAC
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Gender | Male
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Dates
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Enumeration Date | 02/01/2006
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Last Update Date | 10/30/2014
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Provider Practice Location Address
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Address Line | 17 EXCHANGE ST W SUITE 222
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City | SAINT PAUL
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State | MN
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Zip | 55102-1045
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Country | US
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Telephone | 651-224-7854
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Fax |
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Provider Business Mailing Address
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Address Line | 1516 HOLTON ST
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City | SAINT PAUL
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State | MN
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Zip | 55108-2326
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Country | US
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Telephone | 651-644-3119
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 9849
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 9849
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License Number State | MN
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