Healthcare Provider Details

I. General information

NPI: 1750154134
Provider Name (Legal Business Name): ADRIAN ELINGE KANGE PTA,CPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ADRIAN ELINGE KANGE PTA,CPT

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 W SILVER SPRING DR
GLENDALE WI
53209-4415
US

IV. Provider business mailing address

N168W21850 MAIN ST APT 39
JACKSON WI
53037-9395
US

V. Phone/Fax

Practice location:
  • Phone: 414-228-8120
  • Fax:
Mailing address:
  • Phone: 612-242-6173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA2871
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number4061
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: