Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251H1200X | Hand | 6588 |
NPI | 1144337635 |
---|---|
Provider Name | Susan M Wagner |
First Address | Hastings, MN 55033-3212 |
Second Address | Hastings, MN 55033-1648 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/08/2006 |
Last Update Date | 03/04/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
P00366775 | RAILROAD MEDICARE (01) | MN |