Healthcare Provider Details

I. General information

NPI: 1831147099
Provider Name (Legal Business Name): LYNNE E WAGONER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 01/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 MACK RD SUITE 100
FAIRFIELD OH
45014-5335
US

IV. Provider business mailing address

3000 MACK RD SUITE 100
FAIRFIELD OH
45014-5335
US

V. Phone/Fax

Practice location:
  • Phone: 513-751-4222
  • Fax: 513-751-4353
Mailing address:
  • Phone: 513-751-4222
  • Fax: 513-751-4353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35.067216
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207RA0001X
TaxonomyAdvanced Heart Failure and Transplant Cardiology Physician
License Number35.067216
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: