Organization
NORTH STAR PODIATRIC LAB, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. TERRI WAGNER CP (CERTIFIED PEDORTHIST)
(651) 426-9388
Entity
Organization
Contact information
Practice address
13419 FENWAY BLVD N, SUITE 101, HUGO, MN 55038-7465
(651) 426-9388
(651) 426-7450
Mailing address
13419 FENWAY BLVD N, SUITE 101, HUGO, MN 55038-7465
(651) 426-9388
(651) 426-7450
Taxonomy
Speciality
Code
Description
License number
State
335E00000X
Prosthetic/Orthotic Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
26569NO
BLUE CROSS PROVIDER NUMBE
MN
01
—
418173203
METRO HEALTH PLAN PROV NU
MN
01
—
66
HEALTH PARTNERS PROVIDER
MN
01
—
8214553
MEDICA PROVIDER NUMBER
FM
05
—
908817200
—
FM
Enumeration date
07/05/2005
Last updated
05/11/2020
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