Basic Information
| Provider Information | |||||||||
| NPI: | 1962442483 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WANGERIN | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 757 45TH STREET | ||||||||
| Address2: | STE. 201 | ||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199225550 | ||||||||
| FaxNumber: | 2199225555 | ||||||||
| Practice Location | |||||||||
| Address1: | 761 45TH STREET | ||||||||
| Address2: | STE. 103 | ||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199223002 | ||||||||
| FaxNumber: | 2199223003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 10/27/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71000554A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 200286340A | 05 | IN | MEDICAID |