=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992781975
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HOWARD WAGENBERG DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2005
-----------------------------------------------------
Last Update Date | 03/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24 HERON COVE DR
-----------------------------------------------------
City | MERRIMACK
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03054-4866
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-880-9177
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24 HERON COVE DR
-----------------------------------------------------
City | MERRIMACK
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03054-4866
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 157
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------