Provider Demographics
NPI:1053858092
Name:VANWAGNER, ANTHONY (MAOM LAC)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:VANWAGNER
Suffix:
Gender:M
Credentials:MAOM LAC
Other - Prefix:MR
Other - First Name:ANTHONY
Other - Middle Name:BURTON
Other - Last Name:VANWAGNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MAOM LAC
Mailing Address - Street 1:14464 SUMTER AVE
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-1727
Mailing Address - Country:US
Mailing Address - Phone:651-367-9929
Mailing Address - Fax:
Practice Address - Street 1:14464 SUMTER AVE
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-1727
Practice Address - Country:US
Practice Address - Phone:651-367-9929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-29
Last Update Date:2022-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI767-55171100000X
MN1609171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist