Provider Demographics
NPI:1710447875
Name:WANGERIN, MICHAEL KEITH
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KEITH
Last Name:WANGERIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16250 AUDUBON VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63040-1708
Mailing Address - Country:US
Mailing Address - Phone:636-489-9185
Mailing Address - Fax:
Practice Address - Street 1:16250 AUDUBON VILLAGE DR
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63040-1708
Practice Address - Country:US
Practice Address - Phone:636-489-9185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-23
Last Update Date:2019-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant