Provider Demographics
NPI:1801616230
Name:WAGNER, HAILEY LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:HAILEY
Middle Name:LYNN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 EDGAR AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11719-9605
Mailing Address - Country:US
Mailing Address - Phone:631-905-1563
Mailing Address - Fax:
Practice Address - Street 1:1152 KINGS HIGHWAY CUTOFF
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-5271
Practice Address - Country:US
Practice Address - Phone:203-785-2579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-11
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CT6953363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant