Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207K00000X | Allergist & Immunologist | 35398 | MN |
NPI | 1235142308 |
---|---|
Provider Name | Edward Green |
First Address | Morris, MN 56267-0660 |
Second Address | Morris, MN 56267-0660 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/08/2006 |
Last Update Date | 08/07/2007 |