MEDICARE: DR. DIANNE P. WAGNER M.D.

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	207R00000X	Internal Medicine Physician	4301045093	MI

Other Identifiers

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

General Provider Information

NPI Number	:	1407880792
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANNE P. WAGNER M.D.

Provider Business Mailing Address
First Line	:	B338 CLINICAL CENTER
Second Line	:	DEPARTMENT OF MEDICINE
City	:	EAST LANSING
State	:	MI
Zip	:	48824
Country	:	US
Telephone Number	:	517-432-9124
Fax Number	:

Provider Business Practice Location Address
First Line	:	138 SERVICE RD STE A225
Second Line	:
City	:	EAST LANSING
State	:	MI
Zip	:	48824-1376
Country	:	US
Telephone Number	:	517-353-4941
Fax Number	:	517-432-3145

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

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	12/15/2009

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