MARIAH MARIE WAGNER Physician Assistant License verification

Business Entity

ACTIVE

License Type

Physician Assistant

Description

PHYSICIAN ASSISTANT CONTROLLED SUBSTANCE

License Number

38*****52

License Status

ACTIVE

Business

First Name

MARIAH

Middle

MARIE

Last Name

WAGNER

Business Name

MARIAH MARIE WAGNER

Original Issue Date

01/15/2021

Effective Date

02/23/2024

Expiration Date

03/01/2026

City

GRANITE CITY

State

Zip

62040

County

MADISON

Delegated Controlled Substance Schedule

II III IV V

Ever Disciplined

LastModifiedDate

12/03/2025