Healthcare Provider Details

I. General information

NPI: 1215902879
Provider Name (Legal Business Name): EUNICE B WESLANDER PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 11/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 33RD ST S
SAINT CLOUD MN
56301-9668
US

IV. Provider business mailing address

251 COUNTY ROAD 120
SAINT CLOUD MN
56303-4872
US

V. Phone/Fax

Practice location:
  • Phone: 320-251-8181
  • Fax: 320-251-6942
Mailing address:
  • Phone: 320-202-8949
  • Fax: 320-202-0756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8804
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: