Provider Demographics
NPI:1699072140
Name:WAGNER, SHANA L (MSN, FNP-BC)
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:L
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MSN, FNP-BC
Other - Prefix:
Other - First Name:SHANA
Other - Middle Name:L
Other - Last Name:HOGUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, FNP-BC
Mailing Address - Street 1:W2850 STATE ROAD 28
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53085-2702
Mailing Address - Country:US
Mailing Address - Phone:920-467-1800
Mailing Address - Fax:920-467-1900
Practice Address - Street 1:W2850 STATE ROAD 28
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN FALLS
Practice Address - State:WI
Practice Address - Zip Code:53085-2702
Practice Address - Country:US
Practice Address - Phone:920-467-1800
Practice Address - Fax:920-467-1900
Is Sole Proprietor?:No
Enumeration Date:2011-02-18
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI142621163W00000X
WI4381207QH0002X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100014290Medicaid