Provider Demographics
NPI:1952307639
Name:GROOTWASSINK, WESLEY ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:ROBERT
Last Name:GROOTWASSINK
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 1:14001 RIDGEDALE DR
Mailing Address - Street 2:STE 200
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1753
Mailing Address - Country:US
Mailing Address - Phone:952-249-2000
Mailing Address - Fax:952-249-2099
Practice Address - Street 1:14001 RIDGEDALE DR
Practice Address - Street 2:STE 200
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1753
Practice Address - Country:US
Practice Address - Phone:952-249-2000
Practice Address - Fax:952-249-2099
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN36153207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN172828800Medicaid
MN160000825Medicare ID - Type Unspecified
MN172828800Medicaid