Provider Demographics
NPI:1407973894
Name:WAGONER, MICHELE (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:
Last Name:WAGONER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MS
Other - First Name:MICHELE
Other - Middle Name:
Other - Last Name:SHEKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 1671
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21501-1671
Mailing Address - Country:US
Mailing Address - Phone:240-964-8342
Mailing Address - Fax:240-964-8337
Practice Address - Street 1:1050 W INDUSTRIAL BLVD STE 17
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-4331
Practice Address - Country:US
Practice Address - Phone:240-964-9300
Practice Address - Fax:240-964-9310
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV65656363LF0000X
MDR144825363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP00696750Medicare PIN
MD138884Y1ZMedicare PIN
DC022285S58Medicare PIN