Healthcare Provider Details

I. General information

NPI: 1659487239
Provider Name (Legal Business Name): GARY EDWIN WYARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S MAPLE ST
WACONIA MN
55387-1715
US

IV. Provider business mailing address

6465 WAYZATA BLVD SUITE 900
ST LOUIS PARK MN
55426-1728
US

V. Phone/Fax

Practice location:
  • Phone: 952-442-2163
  • Fax: 952-442-5903
Mailing address:
  • Phone: 952-512-5600
  • Fax: 952-512-5650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number18682
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: