Provider Demographics
NPI:1538310990
Name:WIGDAHL, KATIE MCCLELLAN (PA-C)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:MCCLELLAN
Last Name:WIGDAHL
Suffix:
Gender:F
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 1:4848 COUNTY ROAD 101
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-2635
Mailing Address - Country:US
Mailing Address - Phone:952-401-3830
Mailing Address - Fax:
Practice Address - Street 1:10900 WAYZATA BLVD STE 215
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-5505
Practice Address - Country:US
Practice Address - Phone:952-500-0350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-03
Last Update Date:2022-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10512363LF0000X
MN1209363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily