Provider Demographics
NPI:1245305044
Name:VANWAGNEN, AARON MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:AARON
Middle Name:MICHAEL
Last Name:VANWAGNEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1310 GREENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-3077
Mailing Address - Country:US
Mailing Address - Phone:517-787-1990
Mailing Address - Fax:517-787-9183
Practice Address - Street 1:1310 GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-3077
Practice Address - Country:US
Practice Address - Phone:517-787-1990
Practice Address - Fax:517-787-9183
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI078023207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104669435Medicaid
MI104669435Medicaid
MIOP01410Medicare ID - Type Unspecified