Healthcare Provider Details

I. General information

NPI: 1215905427
Provider Name (Legal Business Name): JASON R MAXWELL-WIGGINS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JASON R MAXWELL

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 COMO AVE
SAINT PAUL MN
55108
US

IV. Provider business mailing address

8170 33RD AVE S # MS 21110Q
MINNEAPOLIS MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 651-641-6200
  • Fax: 651-641-6205
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number45055
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: