Provider Demographics
NPI:1023089547
Name:CONROY, ETHAN (PAC)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:CONROY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 HOLTON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-2326
Mailing Address - Country:US
Mailing Address - Phone:651-644-3119
Mailing Address - Fax:
Practice Address - Street 1:17 EXCHANGE ST W
Practice Address - Street 2:SUITE 222
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1045
Practice Address - Country:US
Practice Address - Phone:651-224-7854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9849363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN923192700Medicaid
MNQ17303Medicare UPIN
MN923192700Medicaid