Provider Demographics
NPI:1437878055
Name:WAGNER, MARGARET L (PA)
Entity Type:Individual
Prefix:
First Name:MARGARET
Middle Name:L
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 E COUNTY LINE RD STE B
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1082
Mailing Address - Country:US
Mailing Address - Phone:317-789-9600
Mailing Address - Fax:317-789-0600
Practice Address - Street 1:747 E COUNTY LINE RD STE B
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1082
Practice Address - Country:US
Practice Address - Phone:317-789-9600
Practice Address - Fax:317-789-0600
Is Sole Proprietor?:No
Enumeration Date:2022-08-25
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10003761A363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10003761AOtherPHYSICIAN ASSISTANT LICENSE
IN1698010OtherMEDICARE PTAN