Provider Demographics
NPI:1124128525
Name:WITTCHOW, WILLIAM ALLEN (PA-C)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ALLEN
Last Name:WITTCHOW
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6401 UNIVERSITY AVE NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-4341
Mailing Address - Country:US
Mailing Address - Phone:763-572-5710
Mailing Address - Fax:763-571-3008
Practice Address - Street 1:6341 UNIVERSITY AVE NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-4946
Practice Address - Country:US
Practice Address - Phone:763-572-5710
Practice Address - Fax:763-586-5888
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9684363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1029890OtherPREFERRED ONE
MN6605097OtherMEDICA URGENT CARE
FM251J4WIOtherBCBS OF MN
MNHP33986OtherHEALTHPARTNERS
MN104929OtherUCARE MN
MN25878OtherAMERICA'S PPO
MN0110259OtherMEDICA
MNHP33986OtherHEALTHPARTNERS