Provider Demographics
NPI:1104054923
Name:WAGENER, MARIE SUSAN (DO)
Entity type:Individual
Prefix:DR
First Name:MARIE
Middle Name:SUSAN
Last Name:WAGENER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 CETRONIA RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-9147
Mailing Address - Country:US
Mailing Address - Phone:610-437-2378
Mailing Address - Fax:
Practice Address - Street 1:250 CETRONIA RD
Practice Address - Street 2:SUITE 301
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-9147
Practice Address - Country:US
Practice Address - Phone:610-437-2378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS016478207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology