Individual
JESSEE DAVIS WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
171 ASHLEY AVE, CHARLESTON, SC 29425-5812
(843) 792-1414
Mailing address
PO BOX 751461, CHARLOTTE, NC 28275-1461
(843) 792-6200
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
0001253285
VA
163W00000X
Registered Nurse
292165
NC
367500000X
Certified Registered Nurse Anesthetist
112751
NC
367500000X
Certified Registered Nurse Anesthetist
Primary
22113
SC
Other
Enumeration date
12/14/2016
Last updated
11/12/2018
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