Provider Demographics
NPI:1831147099
Name:WAGONER, LYNNE E (MD)
Entity Type:Individual
Prefix:DR
First Name:LYNNE
Middle Name:E
Last Name:WAGONER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 MACK RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-5335
Mailing Address - Country:US
Mailing Address - Phone:513-751-4222
Mailing Address - Fax:513-751-4353
Practice Address - Street 1:3000 MACK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-5335
Practice Address - Country:US
Practice Address - Phone:513-751-4222
Practice Address - Fax:513-751-4353
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.067216207RC0000X, 207RA0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RA0001XAllopathic & Osteopathic PhysiciansInternal MedicineAdvanced Heart Failure and Transplant Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0982816Medicaid
KY64936057Medicaid
IN200036340Medicaid
F62487Medicare UPIN
OH0982816Medicaid