Healthcare Provider Details

I. General information

NPI: 1356984751
Provider Name (Legal Business Name): SHAWN STEPHENS WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2019
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 E HOSPITAL DR STE 140
WEST COLUMBIA SC
29169-4800
US

IV. Provider business mailing address

1333 TAYLOR ST STE 1C
COLUMBIA SC
29201-2944
US

V. Phone/Fax

Practice location:
  • Phone: 803-936-7076
  • Fax: 803-936-7925
Mailing address:
  • Phone: 803-254-6391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3641
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number1356984751
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: