Provider Demographics
NPI:1073991501
Name:WAGAMAN, AUDREY (PA-C)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:WAGAMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8326 NAAB RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1920
Mailing Address - Country:US
Mailing Address - Phone:317-871-0011
Mailing Address - Fax:317-870-4552
Practice Address - Street 1:8326 NAAB RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1920
Practice Address - Country:US
Practice Address - Phone:317-871-0000
Practice Address - Fax:317-871-0010
Is Sole Proprietor?:No
Enumeration Date:2015-05-17
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical