Provider Demographics
NPI:1346695301
Name:WAGNER, SUSAN RAE (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:RAE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 PEACEFUL ST
Mailing Address - Street 2:
Mailing Address - City:CLINTWOOD
Mailing Address - State:VA
Mailing Address - Zip Code:24228-5081
Mailing Address - Country:US
Mailing Address - Phone:276-220-1845
Mailing Address - Fax:
Practice Address - Street 1:142 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266-4636
Practice Address - Country:US
Practice Address - Phone:276-762-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173497363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily