Healthcare Provider Details

I. General information

NPI: 1376509687
Provider Name (Legal Business Name): RICK JOSEPH WAGNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 E 8TH ST STE 202
WINNER SD
57580-2633
US

IV. Provider business mailing address

825 E 8TH ST STE 202
WINNER SD
57580-2633
US

V. Phone/Fax

Practice location:
  • Phone: 605-842-1612
  • Fax: 605-842-3837
Mailing address:
  • Phone: 605-842-1612
  • Fax: 605-842-3837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4183
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: