Provider Demographics
NPI:1497129563
Name:WAGONER, MARTHA LAINE (FNP)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:LAINE
Last Name:WAGONER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 RIVER HAVEN CIR
Mailing Address - Street 2:APT A
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-4121
Mailing Address - Country:US
Mailing Address - Phone:731-610-6718
Mailing Address - Fax:
Practice Address - Street 1:2102 OTRANTO BLVD
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9841
Practice Address - Country:US
Practice Address - Phone:843-569-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-30
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19800363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily