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NPI Code Detail

MEDICARE: MICHELLE RAE WANNA MD

MEDICARE: MICHELLE RAE WANNA MD
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
1207N00000XDermatology Physician7571SD
2207N00000XDermatology Physician2006012197MO

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1386754307
Entity Type Code : Individual
Provider Name (Legal Business Name) : MICHELLE RAE WANNA MD
Provider Business Mailing Address
First Line : PO BOX 86370
Second Line :
City : SIOUX FALLS
State : SD
Zip : 57118-6370
Country : US
Telephone Number : 605-322-7510
Fax Number : 605-322-6475
Provider Business Practice Location Address
First Line : 6701 S MINNESOTA AVE
Second Line :
City : SIOUX FALLS
State : SD
Zip : 57108-2591
Country : US
Telephone Number : 605-322-6960
Fax Number : 605-322-6961
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/30/2006
Last Update Date : 10/15/2018

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Directions to “ MICHELLE RAE WANNA MD” Practice Location

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