Provider Demographics
NPI:1750601886
Name:SHEN-WAGNER, SIJIE JOY (MD)
Entity type:Individual
Prefix:
First Name:SIJIE
Middle Name:JOY
Last Name:SHEN-WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SIJIE
Other - Middle Name:JOY
Other - Last Name:SHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6174
Mailing Address - Fax:
Practice Address - Street 1:877 W FARIS RD STE A
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4296
Practice Address - Country:US
Practice Address - Phone:864-455-7800
Practice Address - Fax:803-434-7231
Is Sole Proprietor?:No
Enumeration Date:2010-06-11
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME116152207Q00000X
SC38737207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC387370Medicaid
FL009096500Medicaid
FL14R6SOtherBCBSFL
SC387370Medicaid
SCSC69982353Medicare PIN