Basic Information
| Provider Information | |||||||||
| NPI: | 1619948494 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KORSVIK-WYSOCKI | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | KORSVIK | ||||||||
| OtherFirstName: | HOLLY | ||||||||
| OtherMiddleName: | E | ||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11995 SINGLETREE LN | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553445347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525951301 | ||||||||
| FaxNumber: | 6122944903 | ||||||||
| Practice Location | |||||||||
| Address1: | 11913 TALLWOOD CT | ||||||||
| Address2: | |||||||||
| City: | POTOMAC | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208542169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525951100 | ||||||||
| FaxNumber: | 6122944903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 06/23/2015 | ||||||||
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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 | 2085R0202X | DOO47863 | MD | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085P0229X | D47863 | MD | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology |
No ID Information.