Provider Demographics
NPI:1902826449
Name:ADKISSON, WAYNE O (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:O
Last Name:ADKISSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 DELAWARE ST SE
Mailing Address - Street 2:MMC 508
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0341
Mailing Address - Country:US
Mailing Address - Phone:612-625-4401
Mailing Address - Fax:612-624-4937
Practice Address - Street 1:516 DELAWARE ST SE
Practice Address - Street 2:UMMC FAIRVIEW, 3RD FLOOR PWB
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0356
Practice Address - Country:US
Practice Address - Phone:612-625-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101232720207RC0001X
MN42797207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5874211Medicaid
VAC01491Medicare ID - Type UnspecifiedMEDICARE GROUP ID #
VA5874211Medicaid