Healthcare Provider Details

I. General information

NPI: 1164254272
Provider Name (Legal Business Name): EMILY KATHERINE WAGNER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2024
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 RANDOLPH RD FL 3
CHARLOTTE NC
28207-1101
US

IV. Provider business mailing address

4601 PARK RD STE 300
CHARLOTTE NC
28209-2290
US

V. Phone/Fax

Practice location:
  • Phone: 704-323-2543
  • Fax: 704-323-3509
Mailing address:
  • Phone: 704-323-2131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-16381
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: