Basic Information
| Provider Information | |||||||||
| NPI: | 1043461536 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEN | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 E 28TH ST | ||||||||
| Address2: | MAILING CODE 11112 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554073723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128636590 | ||||||||
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| Practice Location | |||||||||
| Address1: | 333 SMITH AVE N | ||||||||
| Address2: | UNITED HOSPITAL | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512418000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2008 | ||||||||
| LastUpdateDate: | 06/10/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 12162 | MN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 363AM0700X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | P67381 | 01 | NY | NYS REGISTRATION | OTHER |