Basic Information
| Provider Information | |||||||||
| NPI: | 1972619690 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLOCK | ||||||||
| FirstName: | LYLE | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | RNFA, PA, ROPA-C | ||||||||
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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: | 775 PRAIRIE CENTER DR | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553447314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529442519 | ||||||||
| FaxNumber: | 9529440460 | ||||||||
| 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 | 364S00000X | R0773991 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |
ID Information
| ID | Type | State | Issuer | Description | 969991011727 | 01 | PREFERREDONE | OTHER | 73B62WI | 01 | BLUECROSS BLUESHIELD | OTHER | HP43945 | 01 | HEALTHPARTNERS | OTHER |