Provider Demographics
NPI:1902801079
Name:WAGNER, SUZANNE (MD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1046 E WENDOVER AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-6712
Mailing Address - Country:US
Mailing Address - Phone:336-272-1050
Mailing Address - Fax:336-272-1110
Practice Address - Street 1:1046 E WENDOVER AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6712
Practice Address - Country:US
Practice Address - Phone:336-272-1050
Practice Address - Fax:336-272-1110
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29970208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC29970OtherNC LICENSE
NC7985192Medicaid
NC7985192Medicaid
F47015Medicare UPIN