Provider Demographics
NPI:1114974284
Name:WAGONER, JOHN A (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:WAGONER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 N ALPHA ST
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-4320
Mailing Address - Country:US
Mailing Address - Phone:308-382-2010
Mailing Address - Fax:308-382-9549
Practice Address - Street 1:800 N ALPHA ST
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4320
Practice Address - Country:US
Practice Address - Phone:308-382-2010
Practice Address - Fax:308-382-9549
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE14621207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47071903800Medicaid
NE281872Medicare PIN
NED05117Medicare UPIN