Healthcare Provider Details

I. General information

NPI: 1962434043
Provider Name (Legal Business Name): PAUL A WAGNER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 08/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 EAST MAIN ST
HART MI
49420-1190
US

IV. Provider business mailing address

611 EAST MAIN STREET
HART MI
49420-1190
US

V. Phone/Fax

Practice location:
  • Phone: 231-873-5675
  • Fax: 231-873-1825
Mailing address:
  • Phone: 231-873-5675
  • Fax: 231-873-1825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPW011554
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101011554
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: