Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 2898 | MN |
NPI | 1336101674 |
---|---|
Provider Name | Dr. Frederick Ashley Clary |
First Address | Roseville, MN 55113-6516 |
Second Address | Roseville, MN 55113-6516 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/04/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
02B04AD | BLUECROSS BLUESHIELD (01) | MN |