Healthcare Provider Details

I. General information

NPI: 1740229566
Provider Name (Legal Business Name): TREVOR JOHN WAGNER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2639 S 159TH PLZ
OMAHA NE
68130-1705
US

IV. Provider business mailing address

6411 S 172ND AVE
OMAHA NE
68135-3080
US

V. Phone/Fax

Practice location:
  • Phone: 402-334-4700
  • Fax: 402-334-0891
Mailing address:
  • Phone: 402-891-1249
  • Fax: 402-334-0891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number1125
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: