Provider Demographics
NPI:1093453565
Name:WAGNER, DUSTIN (PA)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:WAGNER
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Gender:M
Credentials:PA
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Mailing Address - Street 1:3001 QUAIL SPRINGS PKWY FL 5
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-2640
Mailing Address - Country:US
Mailing Address - Phone:405-713-9940
Mailing Address - Fax:405-713-9941
Practice Address - Street 1:5401 N PORTLAND AVE STE 600
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2090
Practice Address - Country:US
Practice Address - Phone:405-713-9940
Practice Address - Fax:405-713-9941
Is Sole Proprietor?:No
Enumeration Date:2022-05-24
Last Update Date:2023-01-12
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Provider Licenses
StateLicense IDTaxonomies
OK4800363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical