Provider Demographics
NPI:1184860074
Name:ERNESTINE WAGNER, PA, INC
Entity Type:Organization
Organization Name:ERNESTINE WAGNER, PA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ERNESTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-979-1309
Mailing Address - Street 1:29306 G C PEERY HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:NORTH TAZEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:24630-9192
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29306 G C PEERY HIGHWAY
Practice Address - Street 2:
Practice Address - City:NORTH TAZEWELL
Practice Address - State:VA
Practice Address - Zip Code:24630-9192
Practice Address - Country:US
Practice Address - Phone:276-979-1309
Practice Address - Fax:188-851-0261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-23
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001577363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty