Provider Demographics
NPI:1952032112
Name:WAGNER, MYESHA J (FNP-C)
Entity Type:Individual
Prefix:MISS
First Name:MYESHA
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1835 SAVOY DR STE 300
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1071
Mailing Address - Country:US
Mailing Address - Phone:678-288-9555
Mailing Address - Fax:678-288-9556
Practice Address - Street 1:132 OLD NORTON RD STE 200
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-4873
Practice Address - Country:US
Practice Address - Phone:678-817-1117
Practice Address - Fax:678-817-0823
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN258179363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG34406AOtherMEDICARE PTAN
GA003274648AMedicaid