Healthcare Provider Details

I. General information

NPI: 1932187465
Provider Name (Legal Business Name): TRACI LEE WAGNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 04/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 ST. JOHNSBURY RD.
LITTLETON NH
03561
US

IV. Provider business mailing address

133 PLEASANT ST
BERLIN NH
03570-2006
US

V. Phone/Fax

Practice location:
  • Phone: 603-444-7070
  • Fax: 603-788-5027
Mailing address:
  • Phone: 603-752-2040
  • Fax: 603-752-3862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12859
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: