Provider Demographics
NPI:1457070823
Name:WAGNER, ANNA
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
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 1:24 LOUDON ST APT 3
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01610-5400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:135 GOLD STAR BLVD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606-2738
Practice Address - Country:US
Practice Address - Phone:508-459-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-26
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program