Healthcare Provider Details

I. General information

NPI: 1861189474
Provider Name (Legal Business Name): MATTHEW STEVEN WAGNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5820 YORK RD STE 201
BALTIMORE MD
21212-3620
US

IV. Provider business mailing address

2644 MILES AVE
BALTIMORE MD
21211-3116
US

V. Phone/Fax

Practice location:
  • Phone: 410-800-2169
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: