Provider Demographics
NPI:1629174503
Name:WADELL, LARRY DEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:DEAN
Last Name:WADELL
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 1:7676 MARINER DR
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-2615
Mailing Address - Country:US
Mailing Address - Phone:763-494-9397
Mailing Address - Fax:763-494-5518
Practice Address - Street 1:631 1ST ST SE
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-6362
Practice Address - Country:US
Practice Address - Phone:507-334-8333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN33713207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN80008017Medicare ID - Type Unspecified
MNE45480Medicare UPIN