Provider Demographics
NPI:1144381401
Name:MICHAEL, DAVONIA NICOLE WAGNER (MD)
Entity Type:Individual
Prefix:
First Name:DAVONIA
Middle Name:NICOLE WAGNER
Last Name:MICHAEL
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 1:507 N LINDSAY ST
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-4303
Mailing Address - Country:US
Mailing Address - Phone:336-883-0029
Mailing Address - Fax:
Practice Address - Street 1:495 ARBOR HILL RD STE M
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-3335
Practice Address - Country:US
Practice Address - Phone:336-883-0029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200300848207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5906844Medicaid
NCP00441368Medicare PIN
NC2065094AMedicare PIN