=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316442361
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEE SHANNON WAGNER M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2018
-----------------------------------------------------
Last Update Date | 09/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5100 N 12TH AVE STE 201
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32504-8919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 448-227-6330
-----------------------------------------------------
Fax | 850-626-9606
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 95590
-----------------------------------------------------
City | SOUTH JORDAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84095-0590
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-352-9500
-----------------------------------------------------
Fax | 801-352-7976
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME176128
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 42864
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------