Healthcare Provider Details

I. General information

NPI: 1013785948
Provider Name (Legal Business Name): WYNONAH FILLA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2023
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MN-65
MORA MN
55051
US

IV. Provider business mailing address

3377 MAUREEN LN
STILLWATER MN
55082-6797
US

V. Phone/Fax

Practice location:
  • Phone: 320-679-1212
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14806
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-15721
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: