Healthcare Provider Details

I. General information

NPI: 1043812787
Provider Name (Legal Business Name): WAYZATA SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 11/09/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 WAYZATA BLVD E STE 200
WAYZATA MN
55391-2513
US

IV. Provider business mailing address

935 WAYZATA BLVD E STE 200
WAYZATA MN
55391-2513
US

V. Phone/Fax

Practice location:
  • Phone: 763-559-4500
  • Fax:
Mailing address:
  • Phone: 763-559-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOHN A NESS
Title or Position: PRESIDENT
Credential: MD
Phone: 763-559-4500