Basic Information
Provider Information | |||||||||
NPI: | 1235457359 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WAGNER | ||||||||
FirstName: | AMANDA | ||||||||
MiddleName: | ELLEN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 636961 | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452636961 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5139815130 | ||||||||
FaxNumber: | 5139815015 | ||||||||
Practice Location | |||||||||
Address1: | 1532 LONE OAK RD | ||||||||
Address2: | SUITE 245 | ||||||||
City: | PADUCAH | ||||||||
State: | KY | ||||||||
PostalCode: | 420037913 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2705385700 | ||||||||
FaxNumber: | 2705385701 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/13/2010 | ||||||||
LastUpdateDate: | 06/08/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 43867 | KY | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 7100131400 | 05 | KY |   | MEDICAID | P00947909 | 01 | KY | RR MEDICARE | OTHER |