Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 56992 | MN |
Y | 207QS0010X | Family Doctor - Sports Medicine | 56992 | MN |
NPI | 1265671671 |
---|---|
Provider Name | Dr. Joshua Shane Maxwell |
First Address | Duluth, MN 55805-1951 |
Second Address | Duluth, MN 55805-1951 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/02/2009 |
Last Update Date | 03/05/2018 |