Provider Demographics
NPI:1467535963
Name:WICKLUND, PAUL EUGENE (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:EUGENE
Last Name:WICKLUND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 HOLDRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-2026
Mailing Address - Country:US
Mailing Address - Phone:952-473-1323
Mailing Address - Fax:
Practice Address - Street 1:1716 HOLDRIDGE CIR
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-2026
Practice Address - Country:US
Practice Address - Phone:952-473-1323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN17419174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist