Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0200X | Nurse Practitioner - Pediatrics | APRN.CNP.10126 | OH |
N | 363LP2300X | Nurse Practitioner - Primary Care | APRNCNP10126 | OH |
NPI | 1043455397 |
---|---|
Provider Name | Mrs. Andrea S Wagner |
First Address | Columbus, OH 43205-2664 |
Second Address | Columbus, OH 43205-2664 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/12/2008 |
Last Update Date | 07/05/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0063702 | (05) | OH |