Provider Demographics
NPI:1114028099
Name:WAGNER, MEGAN (PA-C)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:
Other - Last Name:YUILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7 SCHOOL ST
Mailing Address - Street 2:STE 1
Mailing Address - City:ALBION
Mailing Address - State:ME
Mailing Address - Zip Code:04910-6501
Mailing Address - Country:US
Mailing Address - Phone:207-437-9388
Mailing Address - Fax:207-437-2557
Practice Address - Street 1:7 SCHOOL ST
Practice Address - Street 2:SUITE 1
Practice Address - City:ALBION
Practice Address - State:ME
Practice Address - Zip Code:04910
Practice Address - Country:US
Practice Address - Phone:207-437-9388
Practice Address - Fax:207-437-2557
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1897363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432572499Medicaid
ME432572499Medicaid
ME0000495Medicare PIN