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General NPI Number Information
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NPI Number | 1265623268
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Entity Type | Individual
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Provider Name | JON ANTHONY WAGNON D.O.
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Gender | Male
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Dates
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Enumeration Date | 08/05/2007
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Last Update Date | 05/14/2025
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Provider Practice Location Address
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Address Line | 1368 DADRIAN PROFESSIONAL PARK
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City | GODFREY
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State | IL
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Zip | 62035-1685
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Country | US
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Telephone | 618-433-9701
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Fax | 618-433-9706
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Provider Business Mailing Address
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Address Line | 1368 DADRIAN PROFESSIONAL PARK
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City | GODFREY
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State | IL
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Zip | 62035-1685
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Country | US
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Telephone | 618-433-9701
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Fax | 618-433-9706
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 2006033803
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036120316
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 036120316
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License Number State | IL
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