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NPI Code Detail

MEDICARE: HANS R WAGENAAR PA-C

MEDICARE: HANS R WAGENAAR PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant0447SD

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2970015240OTHERSDRAILROAD MEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1811955073
Entity Type Code : Individual
Provider Name (Legal Business Name) : HANS R WAGENAAR PA-C
Provider Business Mailing Address
First Line : 201 W 69TH ST
Second Line :
City : SIOUX FALLS
State : SD
Zip : 57108-2403
Country : US
Telephone Number : 605-336-0635
Fax Number : 605-336-7182
Provider Business Practice Location Address
First Line : 201 W 69TH ST
Second Line :
City : SIOUX FALLS
State : SD
Zip : 57108-2403
Country : US
Telephone Number : 605-336-0635
Fax Number : 605-336-7182
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/03/2006
Last Update Date : 02/01/2012

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Directions to “ HANS R WAGENAAR PA-C” Practice Location

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