Provider Demographics
NPI:1639220080
Name:WANNER, MICHELLE ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:WANNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3435 PROMENADE AVE APT 705
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-4413
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6150 EGAN DR
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-2699
Practice Address - Country:US
Practice Address - Phone:952-428-3370
Practice Address - Fax:952-428-3371
Is Sole Proprietor?:No
Enumeration Date:2007-01-14
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3553363AM0700X
MN10360363AM0700X, 363A00000X
WI2553-23363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical