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General NPI Number Information
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NPI Number | 1104054923
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Entity Type | Individual
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Provider Name | MARIE SUSAN WAGENER D.O.
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Gender | Female
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Dates
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Enumeration Date | 07/01/2009
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Last Update Date | 08/19/2020
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Provider Practice Location Address
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Address Line | 250 CETRONIA RD SUITE 301
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City | ALLENTOWN
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State | PA
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Zip | 18104-9147
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Country | US
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Telephone | 610-437-2378
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Fax |
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Provider Business Mailing Address
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Address Line | 250 CETRONIA RD SUITE 301
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City | ALLENTOWN
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State | PA
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Zip | 18104-9147
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Country | US
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Telephone | 610-437-2378
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | OS016478
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License Number State | PA
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