Basic Information
| Provider Information | |||||||||
| NPI: | 1801157169 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PLASIC-VAN WAGNER | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 785 5TH AVE STE 3 | ||||||||
| Address2: | |||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172014232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172639555 | ||||||||
| FaxNumber: | 7177096529 | ||||||||
| Practice Location | |||||||||
| Address1: | 964 ISABEL DR | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170427482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172749777 | ||||||||
| FaxNumber: | 7172749815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2012 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP010192 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 102747150 | 05 | PA | MEDICAID | RN212931L | 01 | PA | STATE LICENSE - RN | OTHER | SP010192 | 01 | PA | STATE LICENSE - CRNP | OTHER | 12408945 | 01 | CAQH | OTHER |