Healthcare Provider Details

I. General information

NPI: 1316380694
Provider Name (Legal Business Name): MEREDITH WALL WAGNER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEREDITH LYNN WALL

II. Dates (important events)

Enumeration Date: 04/16/2013
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 SMITHFIELD ST FL 11
PITTSBURGH PA
15222-2222
US

IV. Provider business mailing address

PO BOX 38567
GERMANTOWN TN
38183-0567
US

V. Phone/Fax

Practice location:
  • Phone: 412-224-2336
  • Fax:
Mailing address:
  • Phone: 760-472-3064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD.48544
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA146514
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number58455
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036.165930
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: