Healthcare Provider Details

I. General information

NPI: 1497474605
Provider Name (Legal Business Name): MICHAEL RYAN WOLFENBARGER APRN,FNP-C,PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2022
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4270 S DECATUR BLVD STE B6
LAS VEGAS NV
89103-6802
US

IV. Provider business mailing address

4270 S DECATUR BLVD STE B6
LAS VEGAS NV
89103-6802
US

V. Phone/Fax

Practice location:
  • Phone: 702-485-2100
  • Fax:
Mailing address:
  • Phone: 702-485-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number833732
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: