Individual
MRS. ERNESTINE A WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PA
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
978
WV
363AM0700X
Medical Physician Assistant
0110001577
VA
363AM0700X
Medical Physician Assistant
Primary
1289-23
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
001836169
BLUE CROSS BLUE SHIELD
WV
05
—
10319951
—
VA
01
—
3001613
BRICKSTREET
WV
Enumeration date
05/19/2006
Last updated
06/02/2015
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