Healthcare Provider Details

I. General information

NPI: 1164428223
Provider Name (Legal Business Name): WAYZATA ORTHOPEDIC'S P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 10/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2805 CAMPUS DR STE 425
PLYMOUTH MN
55441-2680
US

IV. Provider business mailing address

2805 CAMPUS DRIVE STE 425
PLYMOUTH MN
55441-2616
US

V. Phone/Fax

Practice location:
  • Phone: 763-383-0770
  • Fax: 763-383-0777
Mailing address:
  • Phone: 763-383-0770
  • Fax: 763-383-0777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number22452
License Number StateMN

VIII. Authorized Official

Name: MR. THOMAS F. VARECKA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 763-383-0770