Provider Demographics
NPI:1316380694
Name:WAGNER, MEREDITH WALL (MD)
Entity type:Individual
Prefix:
First Name:MEREDITH
Middle Name:WALL
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MEREDITH
Other - Middle Name:LYNN
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 38567
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38183-0567
Mailing Address - Country:US
Mailing Address - Phone:760-472-3064
Mailing Address - Fax:
Practice Address - Street 1:1110 MARKET ST STE 210
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37402-2873
Practice Address - Country:US
Practice Address - Phone:629-800-5118
Practice Address - Fax:423-498-9908
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2025-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.48544207N00000X
IL036.165930207N00000X
TN58455207N00000X
CAA146514207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty