Provider Demographics
NPI:1760150692
Name:ADJAGODO, ABIEL KOFFI MADJE (PA-C)
Entity Type:Individual
Prefix:
First Name:ABIEL
Middle Name:KOFFI MADJE
Last Name:ADJAGODO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3297 235TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:SAINT FRANCIS
Mailing Address - State:MN
Mailing Address - Zip Code:55070-9630
Mailing Address - Country:US
Mailing Address - Phone:763-377-5545
Mailing Address - Fax:
Practice Address - Street 1:895 7TH ST E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-3871
Practice Address - Country:US
Practice Address - Phone:763-377-5545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-03
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14697363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant