Healthcare Provider Details

I. General information

NPI: 1073004222
Provider Name (Legal Business Name): KYLE ALAN CASSIDY-WESCOTT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 WABASHA ST S
SAINT PAUL MN
55107-1805
US

IV. Provider business mailing address

611 W PARK ST FAPC
URBANA IL
61801-2500
US

V. Phone/Fax

Practice location:
  • Phone: 952-853-8800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD-48731
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number77850
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036167181
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: