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General NPI Number Information
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NPI Number | 1639220080
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Entity Type | Individual
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Provider Name | MICHELLE ANN WANNER PA-C
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Gender | Female
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Dates
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Enumeration Date | 01/14/2007
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Last Update Date | 10/14/2025
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Provider Practice Location Address
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Address Line | 4801 W 81ST ST STE 112
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City | BLOOMINGTON
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State | MN
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Zip | 55437-1111
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Country | US
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Telephone | 952-345-3000
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Fax | 952-345-6789
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Provider Business Mailing Address
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Address Line | 4801 W 81ST ST STE 112
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City | BLOOMINGTON
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State | MN
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Zip | 55437-1111
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Country | US
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Telephone | 952-913-2907
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Fax | 952-345-6789
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 10360
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 3553
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License Number State | AZ
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Taxonomy #3
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 2553-23
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License Number State | WI
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Taxonomy #4
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 10360
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License Number State | MN
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