Provider Demographics
NPI:1134134968
Name:WUORI, RANDY E (PA-C)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:E
Last Name:WUORI
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 1:135 DAHLIA ST
Mailing Address - Street 2:
Mailing Address - City:MAHTOMEDI
Mailing Address - State:MN
Mailing Address - Zip Code:55115-1632
Mailing Address - Country:US
Mailing Address - Phone:651-653-2089
Mailing Address - Fax:
Practice Address - Street 1:135 DAHLIA ST
Practice Address - Street 2:
Practice Address - City:MAHTOMEDI
Practice Address - State:MN
Practice Address - Zip Code:55115-1632
Practice Address - Country:US
Practice Address - Phone:651-653-2089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10143363AS0400X
WI2045363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q71071Medicare UPIN
WI56080-0033Medicare PIN
Q71071Medicare UPIN
MN037673000Medicaid
WI42890500Medicaid
WI49128-0032Medicare PIN
MN970002674Medicare PIN