Provider Demographics
NPI:1336837459
Name:WAGNER, EMMA SUZANNE
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:SUZANNE
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:PO BOX 1869
Mailing Address - Street 2:
Mailing Address - City:FLETCHER
Mailing Address - State:NC
Mailing Address - Zip Code:28732-1869
Mailing Address - Country:US
Mailing Address - Phone:828-687-5698
Mailing Address - Fax:
Practice Address - Street 1:15 JANE JACOBS RD STE 101
Practice Address - Street 2:
Practice Address - City:BLACK MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28711-8308
Practice Address - Country:US
Practice Address - Phone:828-298-0333
Practice Address - Fax:828-298-0050
Is Sole Proprietor?:No
Enumeration Date:2023-04-26
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-13937363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant