Basic Information
| Provider Information | |||||||||
| NPI: | 1023448313 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WANGEN | ||||||||
| FirstName: | KIM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 1ST DR NW | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559122941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5074337351 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 1ST DR NW | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559122941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5074337351 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2013 | ||||||||
| LastUpdateDate: | 09/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R 127304-3 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 225 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.