Provider Demographics
NPI:1811955073
Name:WAGENAAR, HANS R (PA-C)
Entity type:Individual
Prefix:
First Name:HANS
Middle Name:R
Last Name:WAGENAAR
Suffix:
Gender:M
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 1:201 W 69TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-2403
Mailing Address - Country:US
Mailing Address - Phone:605-336-0635
Mailing Address - Fax:605-336-7182
Practice Address - Street 1:201 W 69TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2403
Practice Address - Country:US
Practice Address - Phone:605-336-0635
Practice Address - Fax:605-336-7182
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0447363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN714427000Medicaid
SD970015240OtherRAILROAD MEDICARE
SD6821680Medicaid
SDP12158Medicare UPIN
MN714427000Medicaid
SD6821680Medicaid
MNP12158Medicare UPIN