Provider Demographics
NPI:1043948607
Name:BADER, WYATT
Entity Type:Individual
Prefix:
First Name:WYATT
Middle Name:
Last Name:BADER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4202 PHEASANT RIDGE DR NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-4529
Mailing Address - Country:US
Mailing Address - Phone:651-255-1498
Mailing Address - Fax:
Practice Address - Street 1:4202 PHEASANT RIDGE DR NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-4529
Practice Address - Country:US
Practice Address - Phone:651-255-1498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN125679183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist