Provider Demographics
NPI:1932187465
Name:WAGNER, TRACI LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACI
Middle Name:LEE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:NH
Mailing Address - Zip Code:03570-2006
Mailing Address - Country:US
Mailing Address - Phone:603-752-2040
Mailing Address - Fax:603-752-3862
Practice Address - Street 1:580 ST. JOHNSBURY RD.
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:NH
Practice Address - Zip Code:03561
Practice Address - Country:US
Practice Address - Phone:603-444-7070
Practice Address - Fax:603-788-5027
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH12859208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30205431Medicaid
VT1011825Medicaid