Individual
IDA JANELLE WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
3509 N BROAD ST, PHILADELPHIA, PA 19140-4105
(215) 707-3933
(215) 707-2531
Mailing address
2450 W HUNTING PARK AVE, PHILADELPHIA, PA 19129-1302
(215) 707-3933
(215) 707-2531
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
25MA11470600
NJ
208600000X
Surgery Physician
MD434346
PA
Other
Enumeration date
07/23/2008
Last updated
08/24/2022
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