Provider Demographics
NPI:1124564240
Name:WANNER, NICHOLAS PETER (PA-C)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:PETER
Last Name:WANNER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1885 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-2979
Mailing Address - Country:US
Mailing Address - Phone:952-993-4001
Mailing Address - Fax:
Practice Address - Street 1:1885 PLAZA DR
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-2979
Practice Address - Country:US
Practice Address - Phone:952-993-4001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical