Provider Demographics
NPI:1861768970
Name:WAGNER, CYNTHIA (NP)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:WAGNER
Other - Last Name:AVELLINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:440 E MARHSALL ST
Mailing Address - Street 2:STE 201
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380-5415
Mailing Address - Country:US
Mailing Address - Phone:610-738-2500
Mailing Address - Fax:
Practice Address - Street 1:440 E MARSHALL ST STE 201
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-5414
Practice Address - Country:US
Practice Address - Phone:610-738-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP011729363LF0000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA440771OtherMLHC MEDICARE GROUP AA #
PA23-2359401OtherMLHC TIN
PA248807HK1Medicare PIN