Provider Demographics
NPI:1558993261
Name:WAGNER, ALI E (FNP-C)
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:E
Last Name:WAGNER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 LANE 12
Mailing Address - Street 2:
Mailing Address - City:LOVELL
Mailing Address - State:WY
Mailing Address - Zip Code:82431-9537
Mailing Address - Country:US
Mailing Address - Phone:307-548-5201
Mailing Address - Fax:
Practice Address - Street 1:1115 LANE 12
Practice Address - Street 2:
Practice Address - City:LOVELL
Practice Address - State:WY
Practice Address - Zip Code:82431-9537
Practice Address - Country:US
Practice Address - Phone:307-548-5201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMF01200522363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
F01200522OtherAANP