Provider Demographics
NPI:1215572128
Name:DEWITT, PATRICK CONLIN (PA-C, MSPAS)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:CONLIN
Last Name:DEWITT
Suffix:
Gender:M
Credentials:PA-C, MSPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 RADIO DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2619
Mailing Address - Country:US
Mailing Address - Phone:952-831-8742
Mailing Address - Fax:
Practice Address - Street 1:155 RADIO DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2619
Practice Address - Country:US
Practice Address - Phone:952-831-8742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13237363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant