Provider Demographics
NPI:1750858981
Name:WAGNER, JOELLE SUSAN (PA)
Entity Type:Individual
Prefix:MISS
First Name:JOELLE
Middle Name:SUSAN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:767 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224
Mailing Address - Country:US
Mailing Address - Phone:716-361-1624
Mailing Address - Fax:
Practice Address - Street 1:767 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224
Practice Address - Country:US
Practice Address - Phone:716-361-1624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025951-01363AS0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program