Provider Demographics
NPI:1427453521
Name:WANDER, KAREN KAY
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:KAY
Last Name:WANDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 HIGHWAY 79 E
Mailing Address - Street 2:
Mailing Address - City:ELBOW LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56531-4647
Mailing Address - Country:US
Mailing Address - Phone:218-685-7300
Mailing Address - Fax:218-685-7296
Practice Address - Street 1:1411 HIGHWAY 79 E
Practice Address - Street 2:
Practice Address - City:ELBOW LAKE
Practice Address - State:MN
Practice Address - Zip Code:56531-4647
Practice Address - Country:US
Practice Address - Phone:218-685-7300
Practice Address - Fax:218-685-7296
Is Sole Proprietor?:No
Enumeration Date:2014-10-31
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA1092225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant