Provider Demographics
NPI:1881611572
Name:WANNER, VICTOR (LAC, RN)
Entity type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:
Last Name:WANNER
Suffix:
Gender:M
Credentials:LAC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 3RD ST W
Mailing Address - Street 2:SUITE 301
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-5136
Mailing Address - Country:US
Mailing Address - Phone:701-483-9150
Mailing Address - Fax:701-483-9150
Practice Address - Street 1:112 3RD ST W
Practice Address - Street 2:SUITE 301
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-5136
Practice Address - Country:US
Practice Address - Phone:701-483-9150
Practice Address - Fax:701-483-9150
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1132101YA0400X
NDR16926163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND09204OtherBCBS PIN
ND54523Medicaid