Provider Demographics
NPI:1366419087
Name:WAGNER, CAROLYN (NP)
Entity type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 E LAKE SHORE DR
Mailing Address - Street 2:SUITE 207
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3832
Mailing Address - Country:US
Mailing Address - Phone:217-429-9700
Mailing Address - Fax:217-429-9702
Practice Address - Street 1:1770 E LAKE SHORE DR
Practice Address - Street 2:SUITE 207
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3832
Practice Address - Country:US
Practice Address - Phone:217-429-9700
Practice Address - Fax:217-429-9702
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-001389363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
S64860Medicare UPIN
K07753Medicare PIN