Provider Demographics
NPI:1700178803
Name:WAGNER, SUSAN (LAC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LAC
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 74
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:AZ
Mailing Address - Zip Code:85641-0074
Mailing Address - Country:US
Mailing Address - Phone:520-955-0575
Mailing Address - Fax:888-501-1017
Practice Address - Street 1:3333 N CAMPBELL AVE
Practice Address - Street 2:SUITE 12
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-2357
Practice Address - Country:US
Practice Address - Phone:520-955-0575
Practice Address - Fax:888-501-1017
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-07
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0696171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist