Healthcare Provider Details

I. General information

NPI: 1255916417
Provider Name (Legal Business Name): VICTORIA JO WACHOLZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2021
Last Update Date: 03/13/2026
Certification Date: 03/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 PRAIRIE CENTER DR STE 400
EDEN PRAIRIE MN
55344-7322
US

IV. Provider business mailing address

2925 CHICAGO AVE
MINNEAPOLIS MN
55407-1321
US

V. Phone/Fax

Practice location:
  • Phone: 952-428-0300
  • Fax:
Mailing address:
  • Phone: 612-262-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14269
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: