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General NPI Number Information
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NPI Number | 1528555794
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Entity Type | Individual
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Provider Name | SAMIULLAH WAGAN MD
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Gender | Male
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Dates
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Enumeration Date | 04/13/2018
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Last Update Date | 09/22/2021
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Provider Practice Location Address
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Address Line | 3700 S MAIN ST
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City | BLACKSBURG
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State | VA
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Zip | 24060-7081
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Country | US
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Telephone | 540-951-1111
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Fax |
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Provider Business Mailing Address
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Address Line | 9721 EVENING BIRD LN
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City | LAUREL
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State | MD
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Zip | 20723-5613
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Country | US
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Telephone | 301-875-2372
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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 | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 0101272610
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License Number State | VA
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