MEDICARE: MICHAEL C WAGNER II FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	209003483	IL

General Provider Information

NPI Number	:	1073655825
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL C WAGNER II FNP

Provider Business Mailing Address
First Line	:	603 N LOGAN AVE
Second Line	:
City	:	DANVILLE
State	:	IL
Zip	:	61832-4320
Country	:	US
Telephone Number	:	217-213-5254
Fax Number	:	217-213-5240

Provider Business Practice Location Address
First Line	:	603 N LOGAN AVE
Second Line	:
City	:	DANVILLE
State	:	IL
Zip	:	61832-4320
Country	:	US
Telephone Number	:	217-213-5254
Fax Number	:	217-213-5240

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/12/2007
Last Update Date	:	11/17/2010

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