Provider Demographics
NPI:1538127337
Name:WAGNER, SHAWN MICHAEL (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:MICHAEL
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 S KING ST
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:NC
Mailing Address - Zip Code:27983-9666
Mailing Address - Country:US
Mailing Address - Phone:252-794-6785
Mailing Address - Fax:252-794-6771
Practice Address - Street 1:1403 S KING ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:NC
Practice Address - Zip Code:27983-9666
Practice Address - Country:US
Practice Address - Phone:252-794-6785
Practice Address - Fax:252-794-6771
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101936363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
2751605AMedicare ID - Type Unspecified
S79267Medicare UPIN