MEDICARE: MS. SUSAN WAGNER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator	857349	NY

General Provider Information

NPI Number	:	1154672400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN WAGNER

Provider Business Mailing Address
First Line	:	12 LANCASTER RD
Second Line	:
City	:	ISLAND PARK
State	:	NY
Zip	:	11558-2136
Country	:	US
Telephone Number	:	347-813-0018
Fax Number	:

Provider Business Practice Location Address
First Line	:	12 LANCASTER RD
Second Line	:
City	:	ISLAND PARK
State	:	NY
Zip	:	11558-2136
Country	:	US
Telephone Number	:	347-813-0018
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2012
Last Update Date	:	09/26/2012

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