=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184696189
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CYNTHIA WETMORE M.D., PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2006
-----------------------------------------------------
Last Update Date | 06/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1012 E 2ND ST
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55805-2200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-249-5555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1012 E 2ND ST
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55805-2200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-249-5555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 30348
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 44137
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------