Provider Demographics
NPI:1588825145
Name:GOLTZ, BENNETT EZRA (PA-C)
Entity type:Individual
Prefix:
First Name:BENNETT
Middle Name:EZRA
Last Name:GOLTZ
Suffix:
Gender:M
Credentials:PA-C
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Other - Credentials:
Mailing Address - Street 1:3643 TURNER DR SW
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-4343
Mailing Address - Country:US
Mailing Address - Phone:612-239-6488
Mailing Address - Fax:952-924-5994
Practice Address - Street 1:6363 FRANCE AVE S STE 103
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435
Practice Address - Country:US
Practice Address - Phone:952-924-5030
Practice Address - Fax:952-924-5994
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2018-08-31
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant