Provider Demographics
NPI:1679914840
Name:WAGNER, AMBER L (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:L
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:AMBER
Other - Middle Name:L
Other - Last Name:WISNIEWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1260 SENTRY DR STE 140
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-5990
Mailing Address - Country:US
Mailing Address - Phone:262-524-1024
Mailing Address - Fax:262-524-8767
Practice Address - Street 1:1260 SENTRY DR STE 140
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-5990
Practice Address - Country:US
Practice Address - Phone:262-524-1024
Practice Address - Fax:262-524-8767
Is Sole Proprietor?:No
Enumeration Date:2013-07-16
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3165-23363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical