1811107683 NPI number — DR. SHARON SANBORN WAGAMON MD

Table of content: DR. SHARON SANBORN WAGAMON MD (NPI 1811107683)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811107683 NPI number — DR. SHARON SANBORN WAGAMON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGAMON
Provider First Name:
SHARON
Provider Middle Name:
SANBORN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SANBORN
Provider Other First Name:
SHARON
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1811107683
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19151 NELSON PARKMAN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARRETTSVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44231-9559
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-468-9239
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
870 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GENEVA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44041-1219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-415-0158
Provider Business Practice Location Address Fax Number:
216-201-8172
Provider Enumeration Date:
05/23/2007

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: 207RH0003X , with the licence number:  57.010919 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2838317 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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