Basic Information
| Provider Information | |||||||||
| NPI: | 1619312642 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LANDON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 52 ROWAYTON AVE | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068531631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613503573 | ||||||||
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| Practice Location | |||||||||
| Address1: | 34 MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068503815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038522000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2013 | ||||||||
| LastUpdateDate: | 12/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 67135 | CT | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 292220 | NY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.