Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RA0401X | Internist - Addiction Medicine | 41140 | MN |
NPI | 1508803610 |
---|---|
Provider Name | Gavin B Bart |
First Address | Minneapolis, MN 55415-1623 |
Second Address | Minneapolis, MN 55415-1623 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/05/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
I40056 | (02) |