Provider Demographics
NPI:1215371349
Name:WAGNER, MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2545 SCHOENERSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18017-7300
Mailing Address - Country:US
Mailing Address - Phone:484-884-2888
Mailing Address - Fax:
Practice Address - Street 1:2545 SCHOENERSVILLE RD
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18017-7300
Practice Address - Country:US
Practice Address - Phone:484-884-2888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-19
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT015047207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine