Provider Demographics
NPI:1124072889
Name:WAGNER, ERNESTINE A (PA)
Entity type:Individual
Prefix:MRS
First Name:ERNESTINE
Middle Name:A
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2417 POST ROAD BUILDING A
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481
Mailing Address - Country:US
Mailing Address - Phone:715-690-1272
Mailing Address - Fax:715-544-1212
Practice Address - Street 1:2417 POST ROAD
Practice Address - Street 2:BUILDING A
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481
Practice Address - Country:US
Practice Address - Phone:715-690-1272
Practice Address - Fax:715-544-1212
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1289-23363AM0700X
WV978363A00000X
VA0110001577363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001836169OtherBLUE CROSS BLUE SHIELD
WV3001613OtherBRICKSTREET
VA10319951Medicaid
WV3001613OtherBRICKSTREET
VA10319951Medicaid