Provider Demographics
NPI:1083719942
Name:WAGNER, MICHAEL E (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:E
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 1:8553 HICKMAN RD
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-4321
Mailing Address - Country:US
Mailing Address - Phone:515-270-5868
Mailing Address - Fax:515-270-5878
Practice Address - Street 1:8553 HICKMAN RD
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-4321
Practice Address - Country:US
Practice Address - Phone:515-270-5868
Practice Address - Fax:515-270-5878
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAAO5587111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0076968Medicaid
IA0076968Medicaid