Basic Information
| Provider Information | |||||||||
| NPI: | 1376554568 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGONER | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5074 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053286585 | ||||||||
| FaxNumber: | 6053286512 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 4TH ST NW | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | SD | ||||||||
| PostalCode: | 572011558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6058868471 | ||||||||
| FaxNumber: | 6058869317 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 10/01/2012 | ||||||||
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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 | 207Q00000X | 40276 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 8597 | SD | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32585100 | 05 | WI | MEDICAID |