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NPI Code Detail

MEDICARE: AMY WAGNER RN

MEDICARE: AMY WAGNER RN
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
1163W00000XRegistered Nurse4704231069MI
2163WC0400XCase Management Registered Nurse4704231069MI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1376997890
Entity Type Code : Individual
Provider Name (Legal Business Name) : AMY WAGNER RN
Provider Business Mailing Address
First Line : 415 CASS ST
Second Line : SUITE 2A & 2D
City : TRAVERSE CITY
State : MI
Zip : 49684-2589
Country : US
Telephone Number : 231-922-4810
Fax Number : 231-943-2590
Provider Business Practice Location Address
First Line : 940 E 8TH ST
Second Line :
City : TRAVERSE CITY
State : MI
Zip : 49686-2893
Country : US
Telephone Number : 231-922-4810
Fax Number : 231-929-0416
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/21/2016
Last Update Date : 04/21/2016

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