Healthcare Provider Details

I. General information

NPI: 1205504339
Provider Name (Legal Business Name): RYNE WILSON RN, OCN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2021
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 1ST ST SW
ROCHESTER MN
55905-0002
US

IV. Provider business mailing address

2415 19TH LN SE
ROCHESTER MN
55904-5809
US

V. Phone/Fax

Practice location:
  • Phone: 507-293-0487
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License NumberR243572-5
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: