Healthcare Provider Details

I. General information

NPI: 1568844900
Provider Name (Legal Business Name): HARRISON WURSTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2015
Last Update Date: 07/13/2020
Certification Date: 07/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14700 28TH AVE N STE 20
PLYMOUTH MN
55447-4876
US

IV. Provider business mailing address

14700 28TH AVE N STE 20
PLYMOUTH MN
55447-4876
US

V. Phone/Fax

Practice location:
  • Phone: 402-499-9459
  • Fax:
Mailing address:
  • Phone: 763-450-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number67659
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: