Provider Demographics
NPI:1053442079
Name:WAGNER, LEE-ANN MARIE (MD)
Entity Type:Individual
Prefix:
First Name:LEE-ANN
Middle Name:MARIE
Last Name:WAGNER
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:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-328-2882
Mailing Address - Fax:410-328-7607
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-2882
Practice Address - Fax:410-328-7607
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD72962208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD417787801Medicaid
MD975341-02 & 03OtherCAREFIRST BC/BS
MDS062-0443OtherCAREFIRST BC/BS REGIONAL
DCP00894783OtherRAILROAD MEDICARE
MDS062-0443OtherCAREFIRST BC/BS REGIONAL
MD417787801Medicaid
MD229788P1YMedicare PIN