Provider Demographics
NPI:1588696900
Name:HALAAS, GWEN ELISE WAGSTROM (MD)
Entity type:Individual
Prefix:DR
First Name:GWEN
Middle Name:ELISE WAGSTROM
Last Name:HALAAS
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:UFP SMILEY'S CLINIC
Mailing Address - Street 2:2615 EAST FRANKLIN AVENUE
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406
Mailing Address - Country:US
Mailing Address - Phone:612-333-0770
Mailing Address - Fax:612-333-0475
Practice Address - Street 1:UFP SMILEY'S CLINIC
Practice Address - Street 2:2615 EAST FRANKLIN AVENUE
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406
Practice Address - Country:US
Practice Address - Phone:612-333-0770
Practice Address - Fax:612-333-0475
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-09
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Provider Licenses
StateLicense IDTaxonomies
MN27862207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0069904Medicaid
MN2057381OtherARAZ
MNHP10534OtherHEALTHPARTNERS
MN100518OtherUCARE
MN428R9HAOtherBCBS
MN1000627OtherPREFERRED ONE
MN01-08658OtherMEDICA CHOICE & PRIMARY
MND81068Medicare UPIN