Healthcare Provider Details

I. General information

NPI: 1326568668
Provider Name (Legal Business Name): ADELE MICHIKO LANGENESS PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ADELE MICHIKO ROCKETT PHYSICIAN ASSISTANT

II. Dates (important events)

Enumeration Date: 06/27/2017
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 W 98TH ST
BLOOMINGTON MN
55420-4773
US

IV. Provider business mailing address

789 RIDGE PL
MENDOTA HEIGHTS MN
55118-4327
US

V. Phone/Fax

Practice location:
  • Phone: 855-324-7843
  • Fax:
Mailing address:
  • Phone: 808-856-9676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13038
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: