Individual
DEBORAH BANAZAK WAGENAAR
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
D.O.
Contact information
Practice address
909 WILSON RD RM B119, EAST LANSING, MI 48824-6410
(517) 353-3070
(517) 884-1817
Mailing address
804 SERVICE RD STE A109B, EAST LANSING, MI 48824-7015
(517) 353-3070
(517) 884-1817
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
5101008530
MI
2084P0805X
Geriatric Psychiatry Physician
Primary
5101008530
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1255315628
—
MI
05
—
3179331
—
MI
Enumeration date
11/30/2005
Last updated
06/29/2023
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