Provider Demographics
NPI:1073809281
Name:WAGNER, MERCY DANIELLE (MD)
Entity Type:Individual
Prefix:
First Name:MERCY
Middle Name:DANIELLE
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 1:260 JOHN PAUL JONES CIR
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321
Mailing Address - Country:US
Mailing Address - Phone:757-953-2544
Mailing Address - Fax:
Practice Address - Street 1:260 JOHN PAUL JONES CIR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708
Practice Address - Country:US
Practice Address - Phone:757-953-5254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-26
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101253448208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery