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General NPI Number Information
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NPI Number | 1154702090
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Entity Type | Individual
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Provider Name | JOEL WAGSTAFF D.O.
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Gender | Male
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Dates
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Enumeration Date | 06/16/2015
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Last Update Date | 05/03/2019
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Provider Practice Location Address
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Address Line | 707 HAMILTON STREET ONE CITY CENTER, 9TH FLOOR
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City | ALLENTOWN
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State | PA
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Zip | 18104-8208
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Country | US
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Telephone | 484-862-3159
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Fax |
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Provider Business Mailing Address
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Address Line | 801 POLE LINE RD W
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City | TWIN FALLS
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State | ID
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Zip | 83301-5810
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208M00000X
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Taxonomy Name | Hospitalist Physician
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License Number | O-1127
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License Number State | ID
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