Provider Demographics
NPI:1407375967
Name:DICKMAN, ADAM JOSEPH (CRNA)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:JOSEPH
Last Name:DICKMAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 47159
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-0159
Mailing Address - Country:US
Mailing Address - Phone:715-410-8744
Mailing Address - Fax:
Practice Address - Street 1:14700 28TH AVE N STE 20
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-4876
Practice Address - Country:US
Practice Address - Phone:763-559-3779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-15
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN117815367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered