1124072889 NPI number — MRS. ERNESTINE A WAGNER PA

Table of content: MRS. ERNESTINE A WAGNER PA (NPI 1124072889)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124072889 NPI number — MRS. ERNESTINE A WAGNER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGNER
Provider First Name:
ERNESTINE
Provider Middle Name:
A
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124072889
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2417 POST ROAD BUILDING A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STEVENS POINT
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54481
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-690-1272
Provider Business Mailing Address Fax Number:
715-544-1212

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2417 POST ROAD
Provider Second Line Business Practice Location Address:
BUILDING A
Provider Business Practice Location Address City Name:
STEVENS POINT
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54481
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-690-1272
Provider Business Practice Location Address Fax Number:
715-544-1212
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  1289-23 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: 978 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 0110001577 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 001836169 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 3001613 . This is a "BRICKSTREET" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 10319951 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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