New Fairview/HealthEast Provider Bio Form

To have a provider bio page created on, please fill out this form as completely as possible and click submit at the bottom of the form. 

NOTE: This form is for new bio pages only - updates to an existing page can be sent to

About you
First Name
Middle Name/Initial
Last Name
Credentials (ex. MD, PT, RN)
Preferred Name (if different from first and last name listed above)
NPI Number
Email Address (Please provide an email address that we can use to contact you with questions. This email will not be displayed publicly.)
Other Languages Spoken
About your practice
Medical/Clinical Title (ex. Nurse Practitioner, Neurologist, Family Medicine Physician)
Hospital Privileges
Clinical Interests (Example: Clinical Research in Interventional Cardiology; Mental health; International Medicine, etc.)
Active Release Technique ART Acupuncture
Athletic Training Back and Neck Care
Blood Flow Restriction Training Chiropractic
Common Conditions Treated Cycle Fit
Dance Program Dry Needling
Figure Skating Gait Analysis and Training
Get Moving Golf Program
Graston Gymnastics
Hand Therapy Hawk Grips
Jaw Disorders TMD Kids in Control
Manual Therapy Mobilization Manipulation MFR McKenzie Mechanical Diagnosis Therapy
Mens Health Musicians
Next Step Nordic Ski
Performing Arts Program Physical Therapy
Pilates Running Program
SCOUT Special Programs
The Brace Program Throwers Program
Treatment Techniques Womens Health
Care Philosophy Statement (Describe your approach in treating and caring for patients. For example, you might consider including how you: Support patient decisions about treatment plans, listen and value your patient input, communicate with patients or educate and encourage patients to be involved in all aspects of their care. Maximum 200 characters and spaces.)
Fairview FPA
Grand Itasca HealthEast
Your care areas
Other Specialties, Overarching Care Areas, Services You Provide
Where do you see patients?
Additional Locations where you see patients (if your location isn't listed above, please type below)
Your education and training (Required)
Medical School (school name, city, state)
Residency (school name, city, state)
Fellowship (school name, city, state - area of specialty)
Other Education
Board Certifications (ex. American Board of Orthopaedic Surgery)
Other Certifications
Leadership Roles
Awards and Recognition