Healthcare Provider Details

I. General information

NPI: 1184860074
Provider Name (Legal Business Name): ERNESTINE WAGNER, PA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2008
Last Update Date: 12/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29306 G C PEERY HIGHWAY
NORTH TAZEWELL VA
24630-9192
US

IV. Provider business mailing address

29306 G C PEERY HIGHWAY
NORTH TAZEWELL VA
24630-9192
US

V. Phone/Fax

Practice location:
  • Phone: 276-979-1309
  • Fax: 188-851-0261
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110001577
License Number StateVA

VIII. Authorized Official

Name: MS. ERNESTINE WAGNER
Title or Position: OWNER
Credential:
Phone: 276-979-1309