Basic Information
| Provider Information | |||||||||
| NPI: | 1932187465 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | TRACI | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 133 PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035702006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037522040 | ||||||||
| FaxNumber: | 6037523862 | ||||||||
| Practice Location | |||||||||
| Address1: | 580 ST. JOHNSBURY RD. | ||||||||
| Address2: | |||||||||
| City: | LITTLETON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034447070 | ||||||||
| FaxNumber: | 6037885027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 04/11/2017 | ||||||||
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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 | 208000000X | 12859 | NH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 30205431 | 05 | NH | MEDICAID | 1011825 | 05 | VT | MEDICAID |