Provider Demographics
NPI:1326539180
Name:WAGNER, MICHELLE DIANE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:DIANE
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 1:1000 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23219-1930
Mailing Address - Country:US
Mailing Address - Phone:804-828-2467
Mailing Address - Fax:
Practice Address - Street 1:1000 E BROAD ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23219-1930
Practice Address - Country:US
Practice Address - Phone:804-828-2467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-28
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101272471208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics