Provider Demographics
NPI:1528421062
Name:WAHL, ELIZABETH PARK (MD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:PARK
Last Name:WAHL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-1166
Mailing Address - Fax:612-262-4258
Practice Address - Street 1:8100 W 78TH ST STE 230
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-2570
Practice Address - Country:US
Practice Address - Phone:952-946-9777
Practice Address - Fax:952-946-9888
Is Sole Proprietor?:No
Enumeration Date:2016-04-01
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61270493207X00000X, 207XS0106X
MN76582207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200099413Medicaid