Basic Information
| Provider Information | |||||||||
| NPI: | 1639892136 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGERS | ||||||||
| FirstName: | MARTI | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 306417 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372306417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9312531110 | ||||||||
| FaxNumber: | 9317229919 | ||||||||
| Practice Location | |||||||||
| Address1: | 980 N MERIDIAN STREET | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473711129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2607033312 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2022 | ||||||||
| LastUpdateDate: | 09/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71013022A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.