Provider Demographics
NPI:1639261969
Name:WAGONER, NELL ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:NELL
Middle Name:ANN
Last Name:WAGONER
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 1:3268 HOSPITAL DR SUITE B
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-7808
Mailing Address - Country:US
Mailing Address - Phone:907-586-1717
Mailing Address - Fax:907-586-2677
Practice Address - Street 1:3268 HOSPITAL DR SUITE B
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-7808
Practice Address - Country:US
Practice Address - Phone:907-586-1717
Practice Address - Fax:907-586-2677
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2531207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK152092OtherINDIV MED
AKMD2531Medicaid
AKMD2531Medicaid
AK152092OtherINDIV MED