Healthcare Provider Details

I. General information

NPI: 1023081577
Provider Name (Legal Business Name): WAYZATA CHILDREN'S CLINIC P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 04/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14001 RIDGEDALE DR #100
MINNETONKA MN
55305-1753
US

IV. Provider business mailing address

14001 RIDGEDALE DR #100
MINNETONKA MN
55305-1753
US

V. Phone/Fax

Practice location:
  • Phone: 952-473-0211
  • Fax: 952-473-7908
Mailing address:
  • Phone: 952-473-0211
  • Fax: 952-473-7908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MARTHA R. ENGELBREKT
Title or Position: PRESIDENT
Credential: MD
Phone: 952-473-0211