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NPI Code Detail

MEDICARE: MS. LISA COLE WAGNER MACCC/SLP

MEDICARE: MS. LISA COLE WAGNER MACCC/SLP
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
1231H00000XAudiologist
2235Z00000XSpeech-Language Pathologist3874NC

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1138GXOTHERNCBLUE CROSS BLUE SHEILD #
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1831141605
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. LISA COLE WAGNER MACCC/SLP
Provider Business Mailing Address
First Line : 4923 BERRY ROSE WAY
Second Line :
City : CARY
State : NC
Zip : 27518-9266
Country : US
Telephone Number : 919-796-2833
Fax Number :
Provider Business Practice Location Address
First Line : 8733 HOLLY SPRINGS RD
Second Line :
City : APEX
State : NC
Zip : 27539-9194
Country : US
Telephone Number : 919-981-6588
Fax Number : 919-981-6255
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/17/2006
Last Update Date : 11/06/2024

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