Provider Demographics
NPI:1174264865
Name:WAGNER, MICHAELA RENEE (DO)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:RENEE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 GEISINGER LN
Mailing Address - Street 2:
Mailing Address - City:LEWISTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17044-3400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21 GEISINGER LN
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:PA
Practice Address - Zip Code:17044-3400
Practice Address - Country:US
Practice Address - Phone:717-242-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAOS024507208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program