Provider Demographics
NPI:1770518599
Name:MITZEL, WYATT L (PA-C)
Entity type:Individual
Prefix:
First Name:WYATT
Middle Name:L
Last Name:MITZEL
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 1:400 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3000 32ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6132
Practice Address - Country:US
Practice Address - Phone:701-364-8000
Practice Address - Fax:701-364-8078
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0269363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND0113522OtherMEDICA #
ND21288OtherNDBS #
NDDA9011029348OtherPREFERRED ONE #
ND0113521OtherMEDICA #
ND1783342OtherAMERICA'S PPO/ARAZ #
ND49G81MIOtherMNBS #
NDHP38584OtherHEALTHPARTNERS #
ND084985500Medicaid
ND21288Medicare ID - Type UnspecifiedND MEDICARE#
NDDA9011029348OtherPREFERRED ONE #
ND060065845Medicare ID - Type UnspecifiedRR MEDICARE #
ND713117Medicare PIN