Provider Demographics
NPI:1710090428
Name:WAGNER, MONTE (NP)
Entity Type:Individual
Prefix:MR
First Name:MONTE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 CORNWALL DR
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06776-5305
Mailing Address - Country:US
Mailing Address - Phone:860-210-8098
Mailing Address - Fax:
Practice Address - Street 1:8 DELAY ST
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6654
Practice Address - Country:US
Practice Address - Phone:203-797-8330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333996363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily