Healthcare Provider Details

I. General information

NPI: 1457582793
Provider Name (Legal Business Name): MATTHEW R WOLDEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2009
Last Update Date: 08/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 EAGAN WOODS DR STE 100
EAGAN MN
55121-1138
US

IV. Provider business mailing address

710 COMMERCE DR STE 200
WOODBURY MN
55125-4925
US

V. Phone/Fax

Practice location:
  • Phone: 651-968-5230
  • Fax:
Mailing address:
  • Phone: 651-968-5042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number10631
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: