Provider Demographics
NPI:1043738214
Name:WAGNER, CARLY JEAN (NP)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:JEAN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 IRVING ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20422-0001
Mailing Address - Country:US
Mailing Address - Phone:202-745-8000
Mailing Address - Fax:
Practice Address - Street 1:50 IRVING ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20422-0001
Practice Address - Country:US
Practice Address - Phone:202-717-6846
Practice Address - Fax:830-239-9756
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-07
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024175304363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner