Healthcare Provider Details

I. General information

NPI: 1194076349
Provider Name (Legal Business Name): DAVID VAN WAGNER MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2012
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2730 PIERCE ST STE 204
SIOUX CITY IA
51104-3764
US

IV. Provider business mailing address

1000 W 4TH ST STE 8
YANKTON SD
57078-3700
US

V. Phone/Fax

Practice location:
  • Phone: 712-234-8787
  • Fax: 712-234-8777
Mailing address:
  • Phone: 605-655-1414
  • Fax: 605-655-1420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID VAN WAGNER
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 712-234-8787