Provider Demographics
NPI:1093892333
Name:WAGNER, RONALD PAUL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:PAUL
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:6180 AMANDA DR
Mailing Address - Street 2:
Mailing Address - City:EATON RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:48827-9689
Mailing Address - Country:US
Mailing Address - Phone:517-782-7415
Mailing Address - Fax:517-782-7483
Practice Address - Street 1:400 HINCKLEY BLVD
Practice Address - Street 2:STE A
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-6125
Practice Address - Country:US
Practice Address - Phone:517-782-7432
Practice Address - Fax:517-782-7483
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601001400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant