NPIMap

Individual provider Active NPI

Ethan M Dekam

  • Physician Assistant
  • Burnsville, MN
National Provider Identifier
1033887385
Registry record updated Oct 20, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
Practice address
14000 Fairview Dr
Burnsville, MN 55337-5713
Phone
(952) 993-8700
NPI assigned
Sep 1, 2021
Last updated
Oct 20, 2023By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Oct 20, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X NU Primary
Student in an Organized Health Care Education/Training Program 390200000X NU

Addresses

Primary practice location

14000 Fairview Dr
Burnsville, MN 55337-5713

Mailing address

8170 33Rd Ave S # Ms 21110Q
Bloomington, MN 55425-4516

Other practice location 1

1830 Greenhaven Ln NE
Owatonna, MN 55060-2152
Phone (507) 676-6687

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20231101000952 MN Practitioner - Physician Assistant 6709232465 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2023
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Park Nicollet ClinicGroup PAC ID 7911819438, 1,778 clinicians

Practice addresses (Care Compare)

5320 Hyland Greens Dr
Bloomington, MN 55437-3934
Phone (952) 993-2400

6500 Excelsior Blvd
St Louis Park, MN 55426-4702
Phone (952) 993-3123

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Park Nicollet Clinic CurrentSince Nov 13, 2023 Accepting new patients

Locations

14000 Fairview Dr
Burnsville, MN 55337
Phone (952) 993-8608

5320 Hyland Greens Dr
Minneapolis, MN 55437
Phone (952) 993-2400

8170 33rd Ave S
#21110Q
Minneapolis, MN 55425
Phone (952) 883-5375

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 7

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1630454400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1697760000000",
    "number": "1033887385",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8170 33RD AVE S # MS 21110Q",
            "city": "BLOOMINGTON",
            "state": "MN",
            "postal_code": "554254516"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "14000 FAIRVIEW DR",
            "city": "BURNSVILLE",
            "state": "MN",
            "postal_code": "553375713",
            "telephone_number": "952-993-8700"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1830 Greenhaven Ln NE",
            "address_purpose": "LOCATION",
            "city": "Owatonna",
            "state": "MN",
            "postal_code": "550602152",
            "country_code": "US",
            "telephone_number": "507-676-6687",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "DEKAM",
        "first_name": "ETHAN",
        "middle_name": "M",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2021-09-01",
        "last_updated": "2023-10-20",
        "certification_date": "2023-10-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Burnsville, MN

Sources for this page

Verify at the official NPI Registry.