Provider Demographics
NPI:1003398959
Name:JACOB-WAGNER, SETH CHRISTOPHER (NP)
Entity Type:Individual
Prefix:MR
First Name:SETH
Middle Name:CHRISTOPHER
Last Name:JACOB-WAGNER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:SETH
Other - Middle Name:
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:343 HOYT ST UPPR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14213-1246
Mailing Address - Country:US
Mailing Address - Phone:716-480-1596
Mailing Address - Fax:
Practice Address - Street 1:114 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14605-2992
Practice Address - Country:US
Practice Address - Phone:585-546-2271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF343222-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty