Provider Demographics
NPI:1417360975
Name:WAGNER, ASHLEY M (OD)
Entity Type:Individual
Prefix:DR
First Name:ASHLEY
Middle Name:M
Last Name:WAGNER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 W OLIVE ST
Mailing Address - Street 2:STE 103
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18508-2573
Mailing Address - Country:US
Mailing Address - Phone:570-823-0290
Mailing Address - Fax:
Practice Address - Street 1:82 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18701-3029
Practice Address - Country:US
Practice Address - Phone:570-823-0290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002919152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist