Provider Demographics
NPI:1427893528
Name:WANNINGER, MICHAEL JAMES (RN BSN)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:WANNINGER
Suffix:
Gender:M
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2304 SE TIBBETTS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-2177
Mailing Address - Country:US
Mailing Address - Phone:916-768-4379
Mailing Address - Fax:
Practice Address - Street 1:2304 SE TIBBETTS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-2177
Practice Address - Country:US
Practice Address - Phone:916-768-4379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10008614390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program