Provider Demographics
NPI:1982019865
Name:WAGNER, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
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 1:128 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:IA
Mailing Address - Zip Code:52211-7711
Mailing Address - Country:US
Mailing Address - Phone:641-522-7221
Mailing Address - Fax:
Practice Address - Street 1:128 JACKSON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:IA
Practice Address - Zip Code:52211-7711
Practice Address - Country:US
Practice Address - Phone:641-522-7221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-30
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant