Provider Demographics
NPI:1417984519
Name:STASSEN-WAGNER, NICOLE ANNE (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:ANNE
Last Name:STASSEN-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 1:601 ELMWOOD AVE
Mailing Address - Street 2:BOX SURG
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-8410
Mailing Address - Country:US
Mailing Address - Phone:585-275-3376
Mailing Address - Fax:585-276-1992
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:BOX SURG
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-8410
Practice Address - Country:US
Practice Address - Phone:585-275-3376
Practice Address - Fax:585-276-1992
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2300092086S0127X, 2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02497487Medicaid
NYJ00001617Medicare PIN
H50731Medicare UPIN