Healthcare Provider Details

I. General information

NPI: 1295699338
Provider Name (Legal Business Name): ADRIAN STAPLES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/12/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 BAPTIST CHURCH RD
FORT TOTTEN ND
58335
US

IV. Provider business mailing address

602 BAPTIST CHURCH RD
FORT TOTTEN ND
58335
US

V. Phone/Fax

Practice location:
  • Phone: 218-851-9091
  • Fax:
Mailing address:
  • Phone: 218-851-9091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License NumberQ000-041-535-400
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: