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NPI Code Detail

MEDICARE: AMY NICOLE WAGNER PA

MEDICARE: AMY NICOLE WAGNER PA
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
1363AM0700XMedical Physician Assistant1704-023WI

General Provider Information

NPI Number : 1326085507
Entity Type Code : Individual
Provider Name (Legal Business Name) : AMY NICOLE WAGNER PA
Provider Business Mailing Address
First Line : 675 W WASHINGTON AVE
Second Line :
City : MADISON
State : WI
Zip : 53703-2637
Country : US
Telephone Number : 608-257-9700
Fax Number : 608-250-2015
Provider Business Practice Location Address
First Line : 675 W WASHINGTON AVE
Second Line :
City : MADISON
State : WI
Zip : 53703-2637
Country : US
Telephone Number : 608-257-9700
Fax Number : 608-250-2015
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/31/2006
Last Update Date : 04/13/2017

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