Provider Demographics
NPI:1790756336
Name:WICKLUND, PAUL T (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:T
Last Name:WICKLUND
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 1:10 N OAKS RD
Mailing Address - Street 2:
Mailing Address - City:NORTH OAKS
Mailing Address - State:MN
Mailing Address - Zip Code:55127-6431
Mailing Address - Country:US
Mailing Address - Phone:651-765-0070
Mailing Address - Fax:
Practice Address - Street 1:17 EXCHANGE ST W
Practice Address - Street 2:SUITE 222
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1045
Practice Address - Country:US
Practice Address - Phone:651-224-7854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-31
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN19937207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN486372100Medicaid
MNA94399Medicare UPIN
MN486372100Medicaid