Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080A0000X | Adolescent Medicine | 29772 | MN |
NPI | 1114007705 |
---|---|
Provider Name | James Michael Marquardt |
First Address | Shoreview, MN 55126-8056 |
Second Address | Shoreview, MN 55126-8056 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/10/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
08280700 | (05) | MN |
D80283 | (02) |