Individual
ETHAN CONROY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PAC
Contact information
Practice address
17 EXCHANGE ST W, SUITE 222, SAINT PAUL, MN 55102-1045
(651) 224-7854
Mailing address
1516 HOLTON ST, SAINT PAUL, MN 55108-2326
(651) 644-3119
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
9849
MN
363AS0400X
Surgical Physician Assistant
Primary
9849
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
923192700
—
MN
Enumeration date
02/01/2006
Last updated
10/30/2014
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