Basic Information
| Provider Information | |||||||||
| NPI: | 1770518599 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITZEL | ||||||||
| FirstName: | WYATT | ||||||||
| MiddleName: | I | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 E 3RD ST | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558051951 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3000 32ND AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581036132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013648000 | ||||||||
| FaxNumber: | 7013648078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 07/10/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PAC0269 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 084985500 | 05 | ND | MEDICAID | 0113521 | 01 | ND | MEDICA # | OTHER | 21288 | 01 | ND | NDBS # | OTHER | 49G81MI | 01 | ND | MNBS # | OTHER | DA9011029348 | 01 | ND | PREFERRED ONE # | OTHER | 0113522 | 01 | ND | MEDICA # | OTHER | 1783342 | 01 | ND | AMERICA'S PPO/ARAZ # | OTHER | HP38584 | 01 | ND | HEALTHPARTNERS # | OTHER |