Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | 20150 | MN |
NPI | 1003834698 |
---|---|
Provider Name | John Stansbury |
First Address | Saint Paul, MN 55108-5113 |
Second Address | Saint Paul, MN 55108-5107 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D81309 | (02) |