Provider Demographics
NPI:1316442361
Name:WAGNER, LEE SHANNON (MD)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:SHANNON
Last Name:WAGNER
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 1:2 SHARPE STREET
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704
Mailing Address - Country:US
Mailing Address - Phone:570-591-5142
Mailing Address - Fax:570-552-8958
Practice Address - Street 1:19140 S 3RD ST
Practice Address - Street 2:
Practice Address - City:CITRONELLE
Practice Address - State:AL
Practice Address - Zip Code:36522-2306
Practice Address - Country:US
Practice Address - Phone:251-866-0086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AL42864207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program