Provider Demographics
NPI:1023180445
Name:WAGENER, JESSICA H (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:H
Last Name:WAGENER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 PORTER DRIVE
Mailing Address - Street 2:SUSAN SPITZNER FINANCE DEPT
Mailing Address - City:MIDDLEBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05753
Mailing Address - Country:US
Mailing Address - Phone:802-388-5607
Mailing Address - Fax:802-388-5654
Practice Address - Street 1:115 PORTER DRIVE
Practice Address - Street 2:PORTER HOSPITAL
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753
Practice Address - Country:US
Practice Address - Phone:802-388-4001
Practice Address - Fax:802-388-5612
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420008940207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN0884Medicaid
VT77V131OtherMVP VT MGD CARE
VT19935OtherBCBS
F84362Medicare UPIN
VND884Medicare ID - Type Unspecified