Healthcare Provider Details

I. General information

NPI: 1760024509
Provider Name (Legal Business Name): ETHAN HEDGES CAPERS PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2019
Last Update Date: 10/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 PRIOR AVE N STE 235E
SAINT PAUL MN
55104-1063
US

IV. Provider business mailing address

PO BOX 860550
MINNEAPOLIS MN
55486-0505
US

V. Phone/Fax

Practice location:
  • Phone: 651-645-8083
  • Fax: 651-645-8078
Mailing address:
  • Phone: 952-924-0199
  • Fax: 952-924-0314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11709
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: