Provider Demographics
NPI:1043096142
Name:WAGNER, AMANDA NICOLE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICOLE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9057 LEXINGTON CT
Mailing Address - Street 2:
Mailing Address - City:BRASELTON
Mailing Address - State:GA
Mailing Address - Zip Code:30517-3470
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9057 LEXINGTON CT
Practice Address - Street 2:
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-3470
Practice Address - Country:US
Practice Address - Phone:770-715-5978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant