Provider Demographics
NPI:1760556856
Name:WAGNER, AMY E
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:E
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:989 RIBAUT RD. SUITE 260
Mailing Address - Street 2:BEAUFORT MEMORIAL PRIMARY CARE
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902
Mailing Address - Country:US
Mailing Address - Phone:843-522-7600
Mailing Address - Fax:843-522-1256
Practice Address - Street 1:955 RIBAUT ROAD
Practice Address - Street 2:BEAUFORT MEMORIAL HOSPITAL BMAC 4TH FLOOR
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902
Practice Address - Country:US
Practice Address - Phone:843-694-1722
Practice Address - Fax:843-522-7430
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA18249363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health