MEDICARE: SHANA L WAGNER MSN, FNP-BC

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	163W00000X	Registered Nurse	142621	WI
2	207QH0002X	Hospice and Palliative Medicine (Family Medicine) Physician	4381	WI
3	363LF0000X	Family Nurse Practitioner	4381	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699072140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANA L WAGNER MSN, FNP-BC

Provider Business Mailing Address
First Line	:	W2850 STATE ROAD 28
Second Line	:
City	:	SHEBOYGAN FALLS
State	:	WI
Zip	:	53085-2702
Country	:	US
Telephone Number	:	920-467-1800
Fax Number	:	920-467-1900

Provider Business Practice Location Address
First Line	:	W2850 STATE ROAD 28
Second Line	:
City	:	SHEBOYGAN FALLS
State	:	WI
Zip	:	53085-2702
Country	:	US
Telephone Number	:	920-467-1800
Fax Number	:	920-467-1900

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

Provider Enumeration Date	:	02/18/2011
Last Update Date	:	01/03/2025

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