Provider Demographics
NPI:1588013288
Name:WAGNER, DANIELLE TAYLOR (PA)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:TAYLOR
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:518-525-5634
Mailing Address - Fax:518-649-4094
Practice Address - Street 1:315 S MANNING BLVD
Practice Address - Street 2:MEDICAL IMAGING DEPARTMENT
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1707
Practice Address - Country:US
Practice Address - Phone:518-525-1852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04548225Medicaid