Provider Demographics
NPI:1902171416
Name:WICKLUND, DAVID ANTHONY
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ANTHONY
Last Name:WICKLUND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2212 44TH AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55412
Mailing Address - Country:US
Mailing Address - Phone:612-868-3334
Mailing Address - Fax:
Practice Address - Street 1:2206 44TH AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55412
Practice Address - Country:US
Practice Address - Phone:612-868-3334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-16
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist