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:
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 1:4801 W 81ST ST STE 112
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55437-1111
Mailing Address - Country:US
Mailing Address - Phone:952-913-2907
Mailing Address - Fax:952-345-6789
Practice Address - Street 1:4801 W 81ST ST STE 112
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55437-1111
Practice Address - Country:US
Practice Address - Phone:952-345-3000
Practice Address - Fax:952-345-6789
Is Sole Proprietor?:No
Enumeration Date:2007-01-14
Last Update Date:2025-03-19
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