Healthcare Provider Details

I. General information

NPI: 1932282878
Provider Name (Legal Business Name): GARY L WAGONER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1337 S GILBERT RD STE 105
MESA AZ
85204
US

IV. Provider business mailing address

PO BOX 9616
CHANDLER HEIGHTS AZ
85227
US

V. Phone/Fax

Practice location:
  • Phone: 480-343-0585
  • Fax: 480-635-1719
Mailing address:
  • Phone: 480-343-0585
  • Fax: 480-635-1719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License Number8098
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberDC28876
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: