Healthcare Provider Details

I. General information

NPI: 1992775027
Provider Name (Legal Business Name): JONI WAGNER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 12/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 S HILL ST
SALEM SD
57058-8760
US

IV. Provider business mailing address

PO BOX 86430
SIOUX FALLS SD
57118-6430
US

V. Phone/Fax

Practice location:
  • Phone: 605-425-2855
  • Fax: 605-425-2149
Mailing address:
  • Phone: 605-322-4900
  • Fax: 605-322-4925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0481
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: