Basic Information
| Provider Information | |||||||||
| NPI: | 1134235385 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROWN-WAGNER | ||||||||
| FirstName: | MARIE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 160 | ||||||||
| Address2: | |||||||||
| City: | SHIPROCK | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874200160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053686401 | ||||||||
| FaxNumber: | 5053686431 | ||||||||
| Practice Location | |||||||||
| Address1: | US HWY 491 NORTH | ||||||||
| Address2: | |||||||||
| City: | SHIPROCK | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053686401 | ||||||||
| FaxNumber: | 5053686431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 02/02/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 131753-2 | NY | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207YX0007X | 50773 | CO | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Plastic Surgery within the Head & Neck |
ID Information
| ID | Type | State | Issuer | Description | 022392 | 01 | CO | KAISER COMMERCIAL NUMBER | OTHER | 621830 | 05 | AZ | MEDICAID | G7888 | 05 | NM | MEDICAID | 23083336 | 05 | CO | MEDICAID |