MEDICARE: PAUL T. WICKLUND, M.D., P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	19937	MN

General Provider Information

NPI Number	:	1407155054
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAUL T. WICKLUND, M.D., P.A.

Provider Business Mailing Address
First Line	:	6545 FRANCE AVE S STE 363
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55435-2121
Country	:	US
Telephone Number	:	952-405-8724
Fax Number	:	952-933-6516

Provider Business Practice Location Address
First Line	:	6545 FRANCE AVE S STE 363
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55435-2121
Country	:	US
Telephone Number	:	952-405-8724
Fax Number	:	952-933-6516

Authorized Official
Title or Position	:	OWNER
Name	:	PAUL T WICKLUND
Credential	:	MD
Telephone Number	:	651-238-3376

Provider Enumeration Date	:	03/22/2011
Last Update Date	:	03/22/2011

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