Provider Demographics
NPI:1407822554
Name:WANDERSEE, STEPHEN C (PA)
Entity type:Individual
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First Name:STEPHEN
Middle Name:C
Last Name:WANDERSEE
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Gender:M
Credentials:PA
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Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:MC21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:952-883-7172
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:640 JACKSON STREET
Practice Address - Street 2:MC 11102F
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2502
Practice Address - Country:US
Practice Address - Phone:651-254-3456
Practice Address - Fax:651-254-5216
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2015-03-24
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Provider Licenses
StateLicense IDTaxonomies
MN8866363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN477448500Medicaid
970002108Medicare ID - Type Unspecified
MN477448500Medicaid