Provider Demographics
NPI:1083780357
Name:WAGNER, CARL (DOM)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DOM
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 28
Mailing Address - Street 2:
Mailing Address - City:CHAMISAL
Mailing Address - State:NM
Mailing Address - Zip Code:87521-0028
Mailing Address - Country:US
Mailing Address - Phone:505-587-2685
Mailing Address - Fax:
Practice Address - Street 1:1332 GUSDORF RD
Practice Address - Street 2:STE. E
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6371
Practice Address - Country:US
Practice Address - Phone:505-758-2700
Practice Address - Fax:505-758-2700
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM341171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist