Provider Demographics
NPI:1063272532
Name:WAGNER, MICHAEL TANNER
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TANNER
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15950 HALEAKALA HWY
Mailing Address - Street 2:
Mailing Address - City:KULA
Mailing Address - State:HI
Mailing Address - Zip Code:96790-8015
Mailing Address - Country:US
Mailing Address - Phone:435-669-5171
Mailing Address - Fax:
Practice Address - Street 1:718 HAIKU RD
Practice Address - Street 2:
Practice Address - City:HAIKU
Practice Address - State:HI
Practice Address - Zip Code:96708-5846
Practice Address - Country:US
Practice Address - Phone:435-669-5171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT-12842225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist