MEDICARE: NICOLE WAWRA L.AC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	2071	MN

General Provider Information

NPI Number	:	1144083221
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE WAWRA L.AC

Provider Business Mailing Address
First Line	:	3340 NORTHDALE BLVD NW STE 120
Second Line	:
City	:	COON RAPIDS
State	:	MN
Zip	:	55448-1622
Country	:	US
Telephone Number	:	763-270-5828
Fax Number	:	763-270-5849

Provider Business Practice Location Address
First Line	:	3340 NORTHDALE BLVD NW STE 120
Second Line	:
City	:	COON RAPIDS
State	:	MN
Zip	:	55448-1622
Country	:	US
Telephone Number	:	763-270-5828
Fax Number	:	763-270-5849

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2024
Last Update Date	:	02/01/2024

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