Provider Demographics
NPI:1124314513
Name:VAN WAGENEN, ERIN R (MD)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:R
Last Name:VAN WAGENEN
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 1:12 HIGH ST STE 302
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7690
Mailing Address - Country:US
Mailing Address - Phone:207-795-5730
Mailing Address - Fax:207-795-5749
Practice Address - Street 1:12 HIGH ST STE 302
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7690
Practice Address - Country:US
Practice Address - Phone:207-795-5730
Practice Address - Fax:207-795-5749
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2025-11-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MEMD20134208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics