Provider Demographics
NPI:1528379237
Name:WAGNER, ROSALIE ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROSALIE
Middle Name:ANN
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 1:520 CREEKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:HUBBARD
Mailing Address - State:OH
Mailing Address - Zip Code:44425-2676
Mailing Address - Country:US
Mailing Address - Phone:330-240-9923
Mailing Address - Fax:
Practice Address - Street 1:520 CREEKSIDE DR
Practice Address - Street 2:
Practice Address - City:HUBBARD
Practice Address - State:OH
Practice Address - Zip Code:44425-2676
Practice Address - Country:US
Practice Address - Phone:330-240-9923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-28
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57015970208000000X
OH096858208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty