Healthcare Provider Details

I. General information

NPI: 1750844908
Provider Name (Legal Business Name): NICHOLAS RUSSELL QUAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2019
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3930 NORTHWOODS DR
ARDEN HILLS MN
55112-6974
US

IV. Provider business mailing address

8170 33RD AVE S
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 651-523-8500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number71131
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number82402
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberMD61411043
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number82402
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: