Healthcare Provider Details

I. General information

NPI: 1740126259
Provider Name (Legal Business Name): ETHAN JEROME TADDY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

2 PINE TREE DR
ARDEN HILLS MN
55112-3754
US

IV. Provider business mailing address

3823 COLGATE AVE
MINNETONKA MN
55345-1706
US

V. Phone/Fax

Practice location:
  • Phone: 651-635-8000
  • Fax:
Mailing address:
  • Phone: 952-378-3882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: