Basic Information
| Provider Information | |||||||||
| NPI: | 1659487239 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WYARD | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | EDWIN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6465 WAYZATA BLVD | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554261728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525125600 | ||||||||
| FaxNumber: | 9525125650 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 S MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553871715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524422163 | ||||||||
| FaxNumber: | 9524425903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 07/11/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 18682 | MN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 73B30WY | 01 | BLUECROSS BLUESHIELD | OTHER | 969990824016 | 01 | PREFERREDONE | OTHER | HP14727 | 01 | HEALTHPARTNERS | OTHER | 10241E948 | 01 | UCARE | OTHER | 928624 | 01 | MEDICA | OTHER |