Healthcare Provider Details

I. General information

NPI: 1306023452
Provider Name (Legal Business Name): CAPSTONE FAMILY MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2008
Last Update Date: 01/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3223 E PALMER WASILLA HWY
WASILLA AK
99654-7236
US

IV. Provider business mailing address

6501 CITY WEST PKWY
EDEN PRAIRIE MN
55344-3248
US

V. Phone/Fax

Practice location:
  • Phone: 952-653-2528
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: WADE ERICKSON
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 952-653-2528