Provider Demographics
NPI:1134235385
Name:BROWN-WAGNER, MARIE (MD)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:BROWN-WAGNER
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:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-0160
Mailing Address - Country:US
Mailing Address - Phone:505-368-6401
Mailing Address - Fax:505-368-6431
Practice Address - Street 1:US HWY 491 NORTH
Practice Address - Street 2:
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420
Practice Address - Country:US
Practice Address - Phone:505-368-6401
Practice Address - Fax:505-368-6431
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY131753-2207Y00000X
CO50773207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO022392OtherKAISER COMMERCIAL NUMBER
AZ621830Medicaid
NMG7888Medicaid
CO23083336Medicaid
CO022392OtherKAISER COMMERCIAL NUMBER
320059Medicare Oscar/Certification
NMG7888Medicaid
COCOAAA3440Medicare PIN