Provider Demographics
NPI:1609203611
Name:WAGIE, ROBERT WILLIAM (MMS, PA-C)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:WILLIAM
Last Name:WAGIE
Suffix:
Gender:M
Credentials:MMS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4490 N BULL RUSH DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8173
Mailing Address - Country:US
Mailing Address - Phone:920-222-9208
Mailing Address - Fax:
Practice Address - Street 1:130 2ND ST
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2883
Practice Address - Country:US
Practice Address - Phone:920-729-2060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-04
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical