Individual
MISS JOELLE SUSAN WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
767 MAIN STREET, WEST SENECA, NY 14224
(716) 361-1624
Mailing address
767 MAIN STREET, WEST SENECA, NY 14224
(716) 361-1624
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
025951-01
NY
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
10/25/2018
Last updated
12/09/2020
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