Healthcare Provider Details

I. General information

NPI: 1144665027
Provider Name (Legal Business Name): MOLLY F WYMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MOLLY FERGUSON FANSLER M.D.

II. Dates (important events)

Enumeration Date: 05/06/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 OAKDALE AVE N
ROBBINSDALE MN
55422-2926
US

IV. Provider business mailing address

3300 OAKDALE AVE N
ROBBINSDALE MN
55422-2926
US

V. Phone/Fax

Practice location:
  • Phone: 763-581-0933
  • Fax: 763-257-8356
Mailing address:
  • Phone: 763-581-0933
  • Fax: 763-257-8356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number61620
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: