Provider Demographics
NPI:1295433241
Name:WAGONER, SAVANNAH ELIZABETH (FNP-BC)
Entity type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:ELIZABETH
Last Name:WAGONER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 HELDERBERG TRAIL
Mailing Address - Street 2:
Mailing Address - City:BERNE
Mailing Address - State:NY
Mailing Address - Zip Code:12023
Mailing Address - Country:US
Mailing Address - Phone:518-872-0009
Mailing Address - Fax:
Practice Address - Street 1:1705 HELDERBERG TRAIL
Practice Address - Street 2:
Practice Address - City:BERNE
Practice Address - State:NY
Practice Address - Zip Code:12023
Practice Address - Country:US
Practice Address - Phone:518-872-0009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF351072363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily