Provider Demographics
NPI:1235280538
Name:WAGONER, SARAH H (PA-C)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:H
Last Name:WAGONER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3361
Mailing Address - Country:US
Mailing Address - Phone:252-338-2151
Mailing Address - Fax:252-338-2505
Practice Address - Street 1:112 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3361
Practice Address - Country:US
Practice Address - Phone:252-338-2151
Practice Address - Fax:252-338-2505
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100350363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7949645Medicaid
NCP04050Medicare UPIN
NC7949645Medicaid