Provider Demographics
NPI:1083791818
Name:WAGNER, JAMES M (DC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:M
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 1:107 RIDGELY AVE
Mailing Address - Street 2:STE. 11
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-1417
Mailing Address - Country:US
Mailing Address - Phone:410-267-0033
Mailing Address - Fax:410-267-0667
Practice Address - Street 1:107 RIDGELY AVE
Practice Address - Street 2:STE. 11
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-1417
Practice Address - Country:US
Practice Address - Phone:410-267-0033
Practice Address - Fax:410-267-0667
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1457/PT111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDM155OtherBCBS
MDW2090001OtherBCBS FEP
MDU61465Medicare UPIN
MD335QMedicare ID - Type Unspecified