Provider Demographics
NPI:1649602749
Name:WAGNER, ERICA L
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:L
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 1:2127 E BROADWAY UNIT A
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-8159
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 OVERLOOK TER
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-2254
Practice Address - Country:US
Practice Address - Phone:608-256-1901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17183-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist