Provider Demographics
NPI:1417143959
Name:WAGNER, MEREDITH G (LRD)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:G
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LRD
Other - Prefix:
Other - First Name:MEREDITH
Other - Middle Name:G
Other - Last Name:STROMSBORG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LRD
Mailing Address - Street 1:700 1ST AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1802
Mailing Address - Country:US
Mailing Address - Phone:701-234-4111
Mailing Address - Fax:701-234-4130
Practice Address - Street 1:700 1ST AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1802
Practice Address - Country:US
Practice Address - Phone:701-234-4111
Practice Address - Fax:701-234-4130
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND731133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND55103Medicaid
NDN712935Medicare PIN