Provider Demographics
NPI:1205979812
Name:WAGNER, SUSAN (NP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6846 BUCKLEY RD
Mailing Address - Street 2:
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-4275
Mailing Address - Country:US
Mailing Address - Phone:315-410-6400
Mailing Address - Fax:315-410-6410
Practice Address - Street 1:6846 BUCKLEY RD
Practice Address - Street 2:
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-4275
Practice Address - Country:US
Practice Address - Phone:315-410-6400
Practice Address - Fax:315-410-6410
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF300531363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01969819Medicaid
NYJ400162315Medicare PIN