Healthcare Provider Details

I. General information

NPI: 1417453366
Provider Name (Legal Business Name): RISA BACHE-WIIG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2018
Last Update Date: 11/07/2022
Certification Date: 11/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5109 36TH AVE N
CRYSTAL MN
55422-2007
US

IV. Provider business mailing address

9201 W BROADWAY AVE STE 601
BROOKLYN PARK MN
55445-1924
US

V. Phone/Fax

Practice location:
  • Phone: 763-587-7900
  • Fax: 763-587-7989
Mailing address:
  • Phone: 763-587-7900
  • Fax: 763-587-7066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number65974
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number65974
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: