MEDICARE: JACK C WAGNER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1093510810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK C WAGNER

Provider Business Mailing Address
First Line	:	800 STANTON L YOUNG BLVD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73104-5018
Country	:	US
Telephone Number	:	405-271-2316
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 N CLASSEN BLVD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73106-5800
Country	:	US
Telephone Number	:	405-760-2673
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/17/2025
Last Update Date	:	02/17/2025

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