Provider Demographics
NPI:1326102617
Name:WAGNER, ANDREA JOAN (MD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:JOAN
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 1:230 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-1408
Mailing Address - Country:US
Mailing Address - Phone:617-591-4263
Mailing Address - Fax:617-591-4272
Practice Address - Street 1:236 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-1495
Practice Address - Country:US
Practice Address - Phone:617-591-4263
Practice Address - Fax:617-591-4272
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA54447208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ04479OtherBLUE CROSS BLUE SHIELD
MAJ04479Medicare ID - Type Unspecified