Healthcare Provider Details

I. General information

NPI: 1093892333
Provider Name (Legal Business Name): RONALD PAUL WAGNER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HINCKLEY BLVD STE A
JACKSON MI
49203-6125
US

IV. Provider business mailing address

6180 AMANDA DR
EATON RAPIDS MI
48827-9689
US

V. Phone/Fax

Practice location:
  • Phone: 517-782-7432
  • Fax: 517-782-7483
Mailing address:
  • Phone: 517-782-7415
  • Fax: 517-782-7483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601001400
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: