Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2084N0400X | Neurologist | 43471 | MN |
NPI | 1023051356 |
---|---|
Provider Name | Gary Wayne Beaver |
First Address | Duluth, MN 55805-1951 |
Second Address | Duluth, MN 55805-1951 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/06/2006 |
Last Update Date | 26/10/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
589126400 | (05) | MN |