Healthcare Provider Details

I. General information

NPI: 1902801079
Provider Name (Legal Business Name): SUZANNE WAGNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1046 E WENDOVER AVE
GREENSBORO NC
27405-6712
US

IV. Provider business mailing address

1046 E WENDOVER AVE
GREENSBORO NC
27405-6712
US

V. Phone/Fax

Practice location:
  • Phone: 336-272-1050
  • Fax: 336-272-1110
Mailing address:
  • Phone: 336-272-1050
  • Fax: 336-272-1110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number29970
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: