Provider Demographics
NPI:1700236114
Name:VAN DER WEGE, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:VAN DER WEGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 19TH ST
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-2502
Mailing Address - Country:US
Mailing Address - Phone:620-792-5700
Mailing Address - Fax:
Practice Address - Street 1:522 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:LARNED
Practice Address - State:KS
Practice Address - Zip Code:67550-3042
Practice Address - Country:US
Practice Address - Phone:620-804-6100
Practice Address - Fax:620-804-6055
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS77268363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner