Healthcare Provider Details

I. General information

NPI: 1902592991
Provider Name (Legal Business Name): JOHN ALLEN WAGNER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2023
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 EAST HOSPITAL RD
FORT GORDON GA
30905-5650
US

IV. Provider business mailing address

300 EAST HOSPITAL ROAD
FORT GORDON GA
30905-5650
US

V. Phone/Fax

Practice location:
  • Phone: 706-787-6945
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number2024037976
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: