Healthcare Provider Details

I. General information

NPI: 1932013976
Provider Name (Legal Business Name): TRENT VANWAGONER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3825 HENDERSHOT AVE NW
WALKER MI
49544-9118
US

IV. Provider business mailing address

3216 BIRCH CREEK CT SE
KENTWOOD MI
49512-1880
US

V. Phone/Fax

Practice location:
  • Phone: 616-965-4267
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704356404
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: