Provider Demographics
NPI:1326125691
Name:WAGNER, GAIL T (NP)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:T
Last Name:WAGNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:GAIL
Other - Middle Name:T
Other - Last Name:WEEDMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APNP
Mailing Address - Street 1:N8311 BACHELORS AVE
Mailing Address - Street 2:
Mailing Address - City:WILLARD
Mailing Address - State:WI
Mailing Address - Zip Code:54493-8774
Mailing Address - Country:US
Mailing Address - Phone:262-844-6369
Mailing Address - Fax:
Practice Address - Street 1:900 ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-3114
Practice Address - Country:US
Practice Address - Phone:715-346-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1741363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1741OtherAPNP WI STATE LIC
WI74729OtherRN WI STATE LIC