Healthcare Provider Details

I. General information

NPI: 1073320602
Provider Name (Legal Business Name): TARA MICHELLE WYLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2024
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17489 DODD BLVD
LAKEVILLE MN
55044-6506
US

IV. Provider business mailing address

2925 CHICAGO AVE
MINNEAPOLIS MN
55407-1321
US

V. Phone/Fax

Practice location:
  • Phone: 952-428-1020
  • Fax:
Mailing address:
  • Phone: 612-262-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15219
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: