Provider Demographics
NPI:1245867399
Name:WAGENER, DELANEY ALIECE (MD (MAY 2020))
Entity type:Individual
Prefix:
First Name:DELANEY
Middle Name:ALIECE
Last Name:WAGENER
Suffix:
Gender:F
Credentials:MD (MAY 2020)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7439 HARWOOD AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-2665
Mailing Address - Country:US
Mailing Address - Phone:906-221-0373
Mailing Address - Fax:
Practice Address - Street 1:6040 UNIVERSITY TOWN CENTRE DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501-2421
Practice Address - Country:US
Practice Address - Phone:304-598-4835
Practice Address - Fax:304-285-7388
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program