Provider Demographics
NPI:1407155054
Name:PAUL T. WICKLUND, M.D., P.A.
Entity Type:Organization
Organization Name:PAUL T. WICKLUND, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:T
Authorized Official - Last Name:WICKLUND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:651-238-3376
Mailing Address - Street 1:6545 FRANCE AVE S STE 363
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2121
Mailing Address - Country:US
Mailing Address - Phone:952-405-8724
Mailing Address - Fax:952-933-6516
Practice Address - Street 1:6545 FRANCE AVE S STE 363
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2121
Practice Address - Country:US
Practice Address - Phone:952-405-8724
Practice Address - Fax:952-933-6516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN19937207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA94399Medicare UPIN