Provider Demographics
NPI:1659487239
Name:WYARD, GARY EDWIN (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:EDWIN
Last Name:WYARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:6465 WAYZATA BLVD
Mailing Address - Street 2:SUITE 900
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1728
Mailing Address - Country:US
Mailing Address - Phone:952-512-5600
Mailing Address - Fax:952-512-5650
Practice Address - Street 1:501 S MAPLE ST
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1715
Practice Address - Country:US
Practice Address - Phone:952-442-2163
Practice Address - Fax:952-442-5903
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN18682207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
73B30WYOtherBLUECROSS BLUESHIELD
969990824016OtherPREFERREDONE
HP14727OtherHEALTHPARTNERS
10241E948OtherUCARE
928624OtherMEDICA
HP14727OtherHEALTHPARTNERS
B58268Medicare UPIN