MEDICARE: MEGAN WALLENBERG

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	367500000X	Certified Registered Nurse Anesthetist	CR000939	SD

General Provider Information

NPI Number	:	1992238042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MEGAN WALLENBERG

Provider Business Mailing Address
First Line	:	1100 E 26TH ST
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57105-4046
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	910 E 20TH ST
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57105-1012
Country	:	US
Telephone Number	:	605-334-6730
Fax Number	:

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

Provider Enumeration Date	:	04/06/2017
Last Update Date	:	04/06/2017

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