Provider Demographics
NPI:1518939750
Name:WAGNER, JENIA (MD)
Entity Type:Individual
Prefix:
First Name:JENIA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 MOUNT HOLYOKE CT
Mailing Address - Street 2:
Mailing Address - City:GETZVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14068-1283
Mailing Address - Country:US
Mailing Address - Phone:716-868-4877
Mailing Address - Fax:716-688-0432
Practice Address - Street 1:292 MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST AURORA
Practice Address - State:NY
Practice Address - Zip Code:14052-1650
Practice Address - Country:US
Practice Address - Phone:716-652-1560
Practice Address - Fax:716-688-0432
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY172214207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10166190OtherFIDELIS
NY00010164304OtherUNIVERA
NY000524001006OtherBC/BS
NY0408107OtherIHA
NY151114BJOtherPREFERRED CARE
NY01608680Medicaid
NY000524001006OtherBC/BS
NY10166190OtherFIDELIS
NY01608680Medicaid