Healthcare Provider Details

I. General information

NPI: 1366443707
Provider Name (Legal Business Name): JOHN PHILIP WUST III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 11/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10705 TOWN SQUARE DR NE STE 100
BLAINE MN
55449-8185
US

IV. Provider business mailing address

2925 CHICAGO AVE
MINNEAPOLIS MN
55407-1321
US

V. Phone/Fax

Practice location:
  • Phone: 763-236-5400
  • Fax:
Mailing address:
  • Phone: 612-262-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number38586
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: