Provider Demographics
NPI:1518308980
Name:WAGNER, DEBRA
Entity Type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 SOUTH AVE STE LL2
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3430
Mailing Address - Country:US
Mailing Address - Phone:718-477-0961
Mailing Address - Fax:718-761-1643
Practice Address - Street 1:1000 SOUTH AVE STE LL2
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3430
Practice Address - Country:US
Practice Address - Phone:718-477-0961
Practice Address - Fax:718-761-1643
Is Sole Proprietor?:No
Enumeration Date:2013-07-12
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1627858174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist