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General NPI Number Information
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NPI Number | 1063272532
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Entity Type | Individual
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Provider Name | MICHAEL TANNER WAGNER
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Gender | Male
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Dates
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Enumeration Date | 03/20/2024
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Last Update Date | 03/20/2024
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Provider Practice Location Address
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Address Line | 718 HAIKU RD
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City | HAIKU
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State | HI
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Zip | 96708-5846
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Country | US
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Telephone | 435-669-5171
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Fax |
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Provider Business Mailing Address
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Address Line | 15950 HALEAKALA HWY
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City | KULA
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State | HI
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Zip | 96790-8015
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Country | US
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Telephone | 435-669-5171
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MAT-12842
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License Number State | HI
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