Provider Demographics
NPI:1639113392
Name:WOLFE, JOHN MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:WOLFE
Suffix:
Gender:M
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 1:2351 CONNECTICUT AVE S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-2477
Mailing Address - Country:US
Mailing Address - Phone:320-259-1411
Mailing Address - Fax:320-259-8967
Practice Address - Street 1:2351 CONNECTICUT AVE S
Practice Address - Street 2:SUITE 200
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2477
Practice Address - Country:US
Practice Address - Phone:320-259-1411
Practice Address - Fax:320-259-8967
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9418363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN683030700Medicaid
MN970005573OtherRAILROAD MEDICARE
MN970000342Medicare ID - Type Unspecified
MN970005573OtherRAILROAD MEDICARE