Provider Demographics
NPI:1699802181
Name:WAGNER, DEBORAH A (PA-C)
Entity type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:A
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:DEBORAH
Other - Middle Name:A
Other - Last Name:MANTEUFEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1025 MARSH ST
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-4752
Mailing Address - Country:US
Mailing Address - Phone:507-625-4032
Mailing Address - Fax:
Practice Address - Street 1:1025 MARSH ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-4752
Practice Address - Country:US
Practice Address - Phone:507-625-4032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN140806363A00000X
WI2099363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41936300Medicaid
WI41936300Medicaid
WIQ76507Medicare UPIN