Basic Information
| Provider Information | |||||||||
| NPI: | 1114028099 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | YUILL | ||||||||
| OtherFirstName: | MEGAN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7 SCHOOL ST | ||||||||
| Address2: | STE 1 | ||||||||
| City: | ALBION | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049106501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074379388 | ||||||||
| FaxNumber: | 2074372557 | ||||||||
| Practice Location | |||||||||
| Address1: | 7 SCHOOL ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | ALBION | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074379388 | ||||||||
| FaxNumber: | 2074372557 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 04/28/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1897 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 432572499 | 05 | ME | MEDICAID |