Provider Demographics
NPI:1043296171
Name:WAGNER, PHILIP JON (DC)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:JON
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PINCKNEY BLVD
Mailing Address - Street 2:NAVAL HOSPITAL BEAUFORT ATTN PROFESSIONAL AFFAIRS
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-6122
Mailing Address - Country:US
Mailing Address - Phone:843-228-5577
Mailing Address - Fax:843-228-5196
Practice Address - Street 1:1 PINCKNEY BLVD
Practice Address - Street 2:NAVAL HOSPITAL BEAUFORT ATTN PROFESSIONAL AFFAIRS
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-6122
Practice Address - Country:US
Practice Address - Phone:843-228-5577
Practice Address - Fax:843-228-5196
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1633111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0900XChiropractic ProvidersChiropractorInternist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000OTHMedicare UPIN