Healthcare Provider Details

I. General information

NPI: 1639892136
Provider Name (Legal Business Name): MARTI WAGERS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2022
Last Update Date: 09/21/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 N MERIDIAN STREET
PORTLAND IN
47371-1129
US

IV. Provider business mailing address

PO BOX 306417
NASHVILLE TN
37230-6417
US

V. Phone/Fax

Practice location:
  • Phone: 260-703-3312
  • Fax:
Mailing address:
  • Phone: 931-253-1110
  • Fax: 931-722-9919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71013022A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: