Provider Demographics
NPI:1154397693
Name:WAGAMON, CHARLOTTE BOWEN (MD)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:BOWEN
Last Name:WAGAMON
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 1:15957 CONNEAUT LAKE ROAD SUITE 3
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335
Mailing Address - Country:US
Mailing Address - Phone:440-858-3175
Mailing Address - Fax:814-724-5295
Practice Address - Street 1:15957 CONNEAUT LAKE ROAD SUITE 3
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335
Practice Address - Country:US
Practice Address - Phone:440-858-3175
Practice Address - Fax:814-724-5295
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044011L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAF00102Medicare UPIN