NPIMap

Individual provider Active NPI

Tara Michelle Wyley

  • Physician Assistant
  • Lakeville, MN
National Provider Identifier
1073320602
Registry record updated Mar 21, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
15219 Issued in MN
Practice address
17489 Dodd Blvd
Lakeville, MN 55044-6506
Phone
(952) 428-1020
NPI assigned
Dec 17, 2024
Last updated
Mar 21, 2025By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 21, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X
Physician Assistant 363A00000X 15219 MN Primary

Addresses

Primary practice location

17489 Dodd Blvd
Lakeville, MN 55044-6506

Mailing address

2925 Chicago Ave
Minneapolis, MN 55407-1321
Phone (612) 262-5000

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address mwyley714617@excellian.direct.allina.com Direct

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20250221002413 MN Practitioner - Physician Assistant 2860912748 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Creighton University School of Medicine, 2024
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Allina Health SystemGroup PAC ID 4587573613, 3,844 clinicians

Practice addresses (Care Compare)

17489 Dodd Blvd
Lakeville, MN 55044-4409
Phone (952) 428-1020

440 Elm St E
Annandale, MN 55302-1109
Phone (320) 682-5225

6350 W 143Rd St
Savage, MN 55378-2890

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
15219MNMDPhysician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Allina Health System CurrentSince Apr 14, 2025 Accepting new patients
Allina Health System CurrentSince Apr 14, 2025 Accepting new patients
Allina Health System Past Accepting new patients

Locations

440 Elm St E
Annandale, MN 55302
Phone (320) 682-5225

17489 Dodd Blvd
Lakeville, MN 55044
Phone (952) 428-1020

2215 Park Ave
Minneapolis, MN 55404
Phone (612) 775-8800

2925 Chicago Ave
Minneapolis, MN 55407
Phone (612) 262-4813

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 15

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 15

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1734393600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1742515200000",
    "number": "1073320602",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2925 CHICAGO AVE",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554071321",
            "telephone_number": "612-262-5000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "17489 DODD BLVD",
            "city": "LAKEVILLE",
            "state": "MN",
            "postal_code": "550446506",
            "telephone_number": "952-428-1020"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WYLEY",
        "first_name": "TARA",
        "middle_name": "MICHELLE",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2024-12-17",
        "last_updated": "2025-03-21",
        "certification_date": "2025-03-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "MN",
            "license": "15219",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "mwyley714617@excellian.direct.allina.com",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "CDA/PDF/TXT",
            "address_1": "17489 Dodd Blvd",
            "city": "Lakeville",
            "state": "MN",
            "country_code": "US",
            "postal_code": "550446506",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Lakeville, MN

Sources for this page

Verify at the official NPI Registry.