Healthcare Provider Details

I. General information

NPI: 1194751552
Provider Name (Legal Business Name): SPORTS AND ORTHOPAEDIC SPECIALISTS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 W 78TH ST SUITE 225
EDINA MN
55439-2516
US

IV. Provider business mailing address

8100 W 78TH ST SUITE 225
EDINA MN
55439-2516
US

V. Phone/Fax

Practice location:
  • Phone: 952-946-9777
  • Fax: 952-946-9888
Mailing address:
  • Phone: 952-946-9777
  • Fax: 952-946-9888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM EVANS
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 952-946-9777