Provider Demographics
NPI:1073531711
Name:WAGNER, ANGELA D (PA-C)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:D
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:D
Other - Last Name:DIEDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2401 41ST ST S
Mailing Address - Street 2:STE 101
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-7783
Mailing Address - Country:US
Mailing Address - Phone:701-234-4023
Mailing Address - Fax:701-234-4050
Practice Address - Street 1:700 1ST AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1802
Practice Address - Country:US
Practice Address - Phone:701-234-4023
Practice Address - Fax:701-234-4050
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0344363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN186186700Medicaid
ND71059Medicaid
ND71059Medicaid
NDN711801Medicare PIN