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General NPI Number Information
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NPI Number | 1356984751
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Entity Type | Individual
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Provider Name | SHAWN STEPHENS WAGNER
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Gender | Female
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Dates
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Enumeration Date | 10/18/2019
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Last Update Date | 07/03/2025
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Provider Practice Location Address
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Address Line | 146 E HOSPITAL DR STE 140
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City | WEST COLUMBIA
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State | SC
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Zip | 29169-4800
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Country | US
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Telephone | 803-936-7076
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Fax | 803-936-7925
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Provider Business Mailing Address
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Address Line | 1333 TAYLOR ST STE 1C
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City | COLUMBIA
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State | SC
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Zip | 29201-2944
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Country | US
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Telephone | 803-254-6391
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 3641
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License Number State | SC
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Taxonomy #3
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | 1356984751
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License Number State | SC
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