Healthcare Provider Details

I. General information

NPI: 1376638221
Provider Name (Legal Business Name): ABBY EMMA MARIE EDGAR ATC/R
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2004 RANDOLPH AVE F-18
SAINT PAUL MN
55105-1750
US

IV. Provider business mailing address

17204 EMBERS AVE
FARMINGTON MN
55024-7336
US

V. Phone/Fax

Practice location:
  • Phone: 651-690-6730
  • Fax:
Mailing address:
  • Phone: 952-460-6349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1870
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: