Healthcare Provider Details

I. General information

NPI: 1871237602
Provider Name (Legal Business Name): LIANNE ROSE WAGNER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22101 MOROSS RD STE 214
DETROIT MI
48236-2148
US

IV. Provider business mailing address

22101 MOROSS RD STE 214
DETROIT MI
48236-2148
US

V. Phone/Fax

Practice location:
  • Phone: 313-343-7110
  • Fax:
Mailing address:
  • Phone: 586-576-4345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: