Provider Demographics
NPI:1275507089
Name:WAGNER, WALLACE J
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1723 GRANDVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51105-1116
Mailing Address - Country:US
Mailing Address - Phone:712-258-1021
Mailing Address - Fax:
Practice Address - Street 1:1723 GRANDVIEW BLVD
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51105-1116
Practice Address - Country:US
Practice Address - Phone:712-258-1021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-16
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA04516111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI14246Medicare ID - Type Unspecified