Active NPI
Marie A Wagner
- Contractor
- Port Saint Lucie, FL
National Provider Identifier
1184895070
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Contractor
- License
- 19-3549-004-08
- Practice address
- 365 SW Log Dr
Port Saint Lucie, FL 34953-7501 - Phone
- (772) 785-6473
- Fax
- (772) 408-0998
- NPI assigned
- Mar 18, 2008
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Contractor | 171W00000X | 19-3549-004-08 | FL | Primary |
Addresses
Primary practice location
365 SW Log Dr
Port Saint Lucie, FL 34953-7501
Mailing address
365 SW Log Dr
Port Saint Lucie, FL 34953-7501
Phone (772) 785-6473
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 19-3549-004-08 | FL | MD | Contractor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1205798400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1205798400000",
"number": "1184895070",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "365 SW LOG DR",
"city": "PORT SAINT LUCIE",
"state": "FL",
"postal_code": "349537501",
"telephone_number": "772-785-6473",
"fax_number": "772-408-0998"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "365 SW LOG DR",
"city": "PORT SAINT LUCIE",
"state": "FL",
"postal_code": "349537501",
"telephone_number": "772-785-6473",
"fax_number": "772-408-0998"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WAGNER",
"first_name": "MARIE",
"middle_name": "A",
"name_prefix": "Ms.",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2008-03-18",
"last_updated": "2008-03-18",
"status": "A"
},
"taxonomies": [
{
"code": "171W00000X",
"taxonomy_group": "",
"desc": "Contractor",
"state": "FL",
"license": "19-3549-004-08",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Port Saint Lucie, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 18, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.