=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639906019
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMBER WAGSTER AUD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2024
-----------------------------------------------------
Last Update Date | 11/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1206 HULL RD SPC 2
-----------------------------------------------------
City | SANDUSKY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44870-6061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-502-3516
-----------------------------------------------------
Fax | 419-324-1110
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1206 HULL RD SPC 2
-----------------------------------------------------
City | SANDUSKY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44870-6061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-502-3516
-----------------------------------------------------
Fax | 419-324-1110
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | 292808
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | A.02537
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------