Basic Information
| Provider Information | |||||||||
| NPI: | 1730382284 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | SHERI | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 MAIN ST FL 5 | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142031009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163230034 | ||||||||
| FaxNumber: | 7163230292 | ||||||||
| Practice Location | |||||||||
| Address1: | 818 ELLICOTT ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142031021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163230034 | ||||||||
| FaxNumber: | 7163230292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2007 | ||||||||
| LastUpdateDate: | 02/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 244296 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000593566005 | 01 | BC/BS | OTHER | 1214325 | 01 | IHA | OTHER | 00028151603 | 01 | UNIVERA | OTHER | 080515000066 | 01 | FIDELIS | OTHER | 080515000092 | 01 | FIDELIS | OTHER | 02904805 | 05 | NY | MEDICAID |