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General NPI Number Information
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NPI Number | 1801567524
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Entity Type | Individual
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Provider Name | BRANDON JAMES WAGNER DC
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Gender | Male
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Dates
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Enumeration Date | 09/22/2021
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Last Update Date | 09/22/2021
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Provider Practice Location Address
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Address Line | 3778 UNION ST
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City | LAFAYETTE
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State | IN
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Zip | 47905-4453
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Country | US
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Telephone | 765-448-1674
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Fax |
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Provider Business Mailing Address
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Address Line | 6504 AMHERST WAY
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City | ZIONSVILLE
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State | IN
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Zip | 46077-9138
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Country | US
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Telephone | 765-412-2490
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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 | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 08003257A
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License Number State | IN
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