=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760115232
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTIAN DANE ADAMS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2022
-----------------------------------------------------
Last Update Date | 02/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 560 S MAPLE ST STE 30
-----------------------------------------------------
City | WACONIA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55387-1759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-442-1774
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10005 GREENBRIER RD APT 222
-----------------------------------------------------
City | HOPKINS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55305-3415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-866-7050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 14952
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------