Provider Demographics
NPI:1386215648
Name:THACKER, ADAM (DPT)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:THACKER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7872 CENTURY BLVD
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-8005
Mailing Address - Country:US
Mailing Address - Phone:952-873-7400
Mailing Address - Fax:
Practice Address - Street 1:16550 W 78TH ST STE B
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55346-4316
Practice Address - Country:US
Practice Address - Phone:952-873-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12320225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist