Provider Demographics
NPI:1518500578
Name:WOLTER, TEIA ROSE
Entity Type:Individual
Prefix:
First Name:TEIA
Middle Name:ROSE
Last Name:WOLTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S
Mailing Address - Street 2:MS 21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:320-253-5220
Mailing Address - Fax:
Practice Address - Street 1:2251 CONNECTICUT AVE S
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2486
Practice Address - Country:US
Practice Address - Phone:320-253-5220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-22
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13223363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant