Provider Demographics
NPI:1760535538
Name:WAGNER, MONICA ELAINE (MD)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:ELAINE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MONICA
Other - Middle Name:ELAINE
Other - Last Name:NANIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3333 E CAMELBACK RD
Mailing Address - Street 2:SUITE 175
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018
Mailing Address - Country:US
Mailing Address - Phone:602-840-3120
Mailing Address - Fax:602-840-3237
Practice Address - Street 1:3333 E CAMELBACK RD
Practice Address - Street 2:SUITE 175
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018
Practice Address - Country:US
Practice Address - Phone:602-840-3120
Practice Address - Fax:602-840-3237
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36955208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ282693Medicaid