Provider Demographics
NPI:1972619690
Name:WILLOCK, LYLE DAVID (RNFA, PA, ROPA-C)
Entity Type:Individual
Prefix:
First Name:LYLE
Middle Name:DAVID
Last Name:WILLOCK
Suffix:
Gender:M
Credentials:RNFA, PA, ROPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last 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 1:775 PRAIRIE CENTER DR
Practice Address - Street 2:SUITE 250
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-7314
Practice Address - Country:US
Practice Address - Phone:952-944-2519
Practice Address - Fax:952-944-0460
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
MNR0773991364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
969991011727OtherPREFERREDONE
73B62WIOtherBLUECROSS BLUESHIELD
HP43945OtherHEALTHPARTNERS