Basic Information
| Provider Information | |||||||||
| NPI: | 1760556856 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | E. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 989 RIBAUT RD. SUITE 260 | ||||||||
| Address2: | BEAUFORT MEMORIAL PRIMARY CARE | ||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435227600 | ||||||||
| FaxNumber: | 8435221256 | ||||||||
| Practice Location | |||||||||
| Address1: | 955 RIBAUT ROAD | ||||||||
| Address2: | BEAUFORT MEMORIAL HOSPITAL BMAC 4TH FLOOR | ||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436941722 | ||||||||
| FaxNumber: | 8435227430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 06/12/2017 | ||||||||
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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 | 363LA2200X | A18249 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.