Individual
WANDA J ETHEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
4155 COUNTY ROAD 101 N, PLYMOUTH, MN 55446-2307
(952) 993-8900
Mailing address
8170 33RD AVE S, PO BOX 1309 MAIL STOP 21110Q, MINNEAPOLIS, MN 55425-4516
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
116865
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
160026
BCBS
—
05
—
203793518
—
MO
01
—
P00223231
RAILROAD MEDICARE
—
Enumeration date
06/16/2006
Last updated
06/30/2016
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