Provider Demographics
NPI:1043425341
Name:WAGNER, DUKE ELVIN (PHD)
Entity Type:Individual
Prefix:
First Name:DUKE
Middle Name:ELVIN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2192
Mailing Address - Street 2:
Mailing Address - City:PEARL CITY
Mailing Address - State:HI
Mailing Address - Zip Code:96782-9192
Mailing Address - Country:US
Mailing Address - Phone:808-254-5468
Mailing Address - Fax:808-262-4437
Practice Address - Street 1:970 N KALAHEO AVE
Practice Address - Street 2:A204
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-1801
Practice Address - Country:US
Practice Address - Phone:808-254-5468
Practice Address - Fax:808-262-4437
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY298103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000003889OtherHMSA
HI00461901Medicaid