Provider Demographics
NPI:1013589407
Name:WAGNER, LUKE ANDREW (SOIDC)
Entity Type:Individual
Prefix:
First Name:LUKE
Middle Name:ANDREW
Last Name:WAGNER
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-1313
Mailing Address - Country:US
Mailing Address - Phone:305-793-4777
Mailing Address - Fax:
Practice Address - Street 1:917 3RD ST
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-1313
Practice Address - Country:US
Practice Address - Phone:305-793-4777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman