Provider Demographics
NPI:1194187864
Name:WAGNER, GRETCHEN (MD)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:WAGNER
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:W6981 PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54942-8034
Mailing Address - Country:US
Mailing Address - Phone:920-882-2400
Mailing Address - Fax:
Practice Address - Street 1:W6981 PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:WI
Practice Address - Zip Code:54942-8034
Practice Address - Country:US
Practice Address - Phone:920-882-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI67986-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine