Basic Information
| Provider Information | |||||||||
| NPI: | 1407880792 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | DIANNE | ||||||||
| MiddleName: | P. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | B338 CLINICAL CENTER | ||||||||
| Address2: | DEPARTMENT OF MEDICINE | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5174329124 | ||||||||
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| Practice Location | |||||||||
| Address1: | 138 SERVICE RD STE A225 | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488241376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173534941 | ||||||||
| FaxNumber: | 5174323145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 12/15/2009 | ||||||||
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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 | 207R00000X | 4301045093 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1540886 | 05 | MI | MEDICAID |