Provider Demographics
NPI:1417411349
Name:WAGNER, RANDI LYNN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:RANDI
Middle Name:LYNN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 STRINGER ST
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37405-3228
Mailing Address - Country:US
Mailing Address - Phone:651-261-3878
Mailing Address - Fax:
Practice Address - Street 1:320 STRINGER ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37405-3228
Practice Address - Country:US
Practice Address - Phone:651-261-3878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-24
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA062350363A00000X
TN4258363A00000X
MSPA00517363A00000X
VA0110007083363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant