Basic Information
| Provider Information | |||||||||
| NPI: | 1184698557 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WULF | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ANP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GREENWOOD | ||||||||
| OtherFirstName: | JUDITH | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1309 - 8170 33RD AVE S | ||||||||
| Address2: | MAIL STOP 21110Q | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554254516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512547900 | ||||||||
| FaxNumber: | 6512547904 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 PHALEN BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | ST. PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551305302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512547900 | ||||||||
| FaxNumber: | 6512547904 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 10/01/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | CNP2302 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 04-10205 | 01 | MN | MEDICA | OTHER | 1184698557 | 05 | MN | MEDICAID | 43917100 | 05 | WI | MEDICAID |