Basic Information
| Provider Information | |||||||||
| NPI: | 1750601886 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHEN-WAGNER | ||||||||
| FirstName: | SIJIE | ||||||||
| MiddleName: | JOY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHEN | ||||||||
| OtherFirstName: | SIJIE | ||||||||
| OtherMiddleName: | JOY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 INDEPENDENCE PT STE 212 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647976174 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 877 W FARIS RD STE A | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296054296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644557800 | ||||||||
| FaxNumber: | 8034347231 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2010 | ||||||||
| LastUpdateDate: | 09/13/2018 | ||||||||
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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 | 207Q00000X | ME116152 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 38737 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 387370 | 05 | SC | MEDICAID | 009096500 | 05 | FL | MEDICAID | 14R6S | 01 | FL | BCBSFL | OTHER |