Provider Demographics
NPI:1083824593
Name:WAGNER, LISA (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
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 1:170 E 87TH ST
Mailing Address - Street 2:PH2B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-2214
Mailing Address - Country:US
Mailing Address - Phone:917-492-8702
Mailing Address - Fax:917-492-8702
Practice Address - Street 1:1250 BROADWAY, 17TH FLOOR
Practice Address - Street 2:VISITING NURSE SERVICE OF NEW YORK
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001
Practice Address - Country:US
Practice Address - Phone:212-465-2751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY430343363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYLW385602OtherNYS HEALTH COMMERCE SYSTEM