Provider Demographics
NPI:1003085184
Name:WAGNER, MICHAEL HILMAR (RD, LD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:HILMAR
Last Name:WAGNER
Suffix:
Gender:M
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2265 COMO AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-1737
Mailing Address - Country:US
Mailing Address - Phone:651-645-5323
Mailing Address - Fax:651-647-5135
Practice Address - Street 1:2265 COMO AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-1737
Practice Address - Country:US
Practice Address - Phone:888-364-5977
Practice Address - Fax:844-385-4630
Is Sole Proprietor?:No
Enumeration Date:2008-02-22
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNN177133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist