Provider Demographics
NPI:1124314513
Name:VAN WAGENEN, ERIN R (MD)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:R
Last Name:VAN WAGENEN
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 1:100 GANNETT DRIVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-662-7066
Practice Address - Street 1:259 MAIN STREET
Practice Address - Street 2:
Practice Address - City:YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04096
Practice Address - Country:US
Practice Address - Phone:207-846-9602
Practice Address - Fax:207-662-7066
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD20134208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics