Basic Information
| Provider Information | |||||||||
| NPI: | 1326125691 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | GAIL | ||||||||
| MiddleName: | T. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WEEDMAN | ||||||||
| OtherFirstName: | GAIL | ||||||||
| OtherMiddleName: | T. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | N8311 BACHELORS AVE | ||||||||
| Address2: | |||||||||
| City: | WILLARD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544938774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628446369 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 900 ILLINOIS AVE | ||||||||
| Address2: | |||||||||
| City: | STEVENS POINT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544813114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153465000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 09/21/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 1741 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1741 | 01 | WI | APNP WI STATE LIC | OTHER | 74729 | 01 | WI | RN WI STATE LIC | OTHER |