Healthcare Provider Details

I. General information

NPI: 1205819232
Provider Name (Legal Business Name): CHARLES WAGNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 03/25/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S MERCER ST 4TH FLOOR
NEW CASTLE PA
16101-4672
US

IV. Provider business mailing address

2 HOT METAL ST QUANTUM ONE SUITE 001
PITTSBURGH PA
15203-2348
US

V. Phone/Fax

Practice location:
  • Phone: 724-656-6090
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS015833
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: