Provider Demographics
NPI:1184643587
Name:WAGNER, HENRY W (MD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:W
Last Name:WAGNER
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 1:1 PARKLAND DR
Mailing Address - Street 2:
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-2746
Mailing Address - Country:US
Mailing Address - Phone:603-421-2220
Mailing Address - Fax:603-421-2223
Practice Address - Street 1:1 PARKLAND DR
Practice Address - Street 2:
Practice Address - City:DERRY
Practice Address - State:NH
Practice Address - Zip Code:03038-2746
Practice Address - Country:US
Practice Address - Phone:603-421-2220
Practice Address - Fax:603-421-2223
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2008-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH11547207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH01Y003778NH02OtherANTHEM
7770294OtherAETNA
436810OtherHARVARD PILGRIM
MA2093171Medicaid
37305OtherBMC HEALTHNET
NH30201995Medicaid
P00209518OtherRAILROAD MEDICARE
7770294OtherAETNA
NHRE6567Medicare PIN
NHUX5291Medicare PIN