Provider Demographics
NPI:1033979828
Name:WAGERS, DANNA-GRACE BOYD
Entity Type:Individual
Prefix:
First Name:DANNA-GRACE
Middle Name:BOYD
Last Name:WAGERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 BRIX DR
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-2643
Mailing Address - Country:US
Mailing Address - Phone:770-842-9133
Mailing Address - Fax:
Practice Address - Street 1:2200 MEDICAL CENTER BLVD STE 400
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7769
Practice Address - Country:US
Practice Address - Phone:770-758-7482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12232363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical