Provider Demographics
NPI:1700106739
Name:WAGNER, SHELLEY E (MD)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:E
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:
Other - Last Name:WAITS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:43 WHITING HILL RD STE 300
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-1006
Mailing Address - Country:US
Mailing Address - Phone:207-973-5000
Mailing Address - Fax:207-973-5042
Practice Address - Street 1:895 UNION ST STE 12
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3054
Practice Address - Country:US
Practice Address - Phone:207-973-7979
Practice Address - Fax:207-947-9579
Is Sole Proprietor?:No
Enumeration Date:2010-06-01
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL31246207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine