Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RC0000X | Internist - Cardiovascular Disease | 40622 | MN |
N | 208D00000X | General Practice Physician | 40622 | MN |
NPI | 1003880865 |
---|---|
Provider Name | Mark E Wylam |
First Address | Rochester, MN 55905-0001 |
Second Address | Rochester, MN 55905-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/02/2006 |
Last Update Date | 21/08/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
C43658 | (02) |