Healthcare Provider Details

I. General information

NPI: 1942425061
Provider Name (Legal Business Name): SCOTT D WISSINK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 NORTHLAND DR
BLOOMINGTON MN
55431-4800
US

IV. Provider business mailing address

8170 33RD AVE S MAILSTOP 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 952-831-8742
  • Fax: 952-831-1626
Mailing address:
  • Phone: 952-883-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD427066
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number53239
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: