Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LC0200X | Nurse Practitioner - Critical Care Medicine | R174093 | MD |
NPI | 1356891105 |
---|---|
Provider Name | Mrs. Melissa Wagner |
First Address | Bel Air, MD 21015-5780 |
Second Address | Baltimore, MD 21201-1544 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/10/2016 |
Last Update Date | 05/10/2016 |