Healthcare Provider Details

I. General information

NPI: 1881968535
Provider Name (Legal Business Name): SALEM MICHELLE WAGNER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2012
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 W 21ST ST
ANDOVER KS
67002-5500
US

IV. Provider business mailing address

1124 W 21ST ST
ANDOVER KS
67002-5500
US

V. Phone/Fax

Practice location:
  • Phone: 785-392-7620
  • Fax: 316-300-4040
Mailing address:
  • Phone: 785-392-7620
  • Fax: 316-300-4040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number13-83024-122
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: