Provider Demographics
NPI:1306213319
Name:STOKEN WAGNER OPHTHALMIC ASSOCIATES, LLC
Entity Type:Organization
Organization Name:STOKEN WAGNER OPHTHALMIC ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HOFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:717-249-6337
Mailing Address - Street 1:338 ALEXANDER SPRING RD
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:PA
Mailing Address - Zip Code:17015-9129
Mailing Address - Country:US
Mailing Address - Phone:717-249-6337
Mailing Address - Fax:717-249-2415
Practice Address - Street 1:338 ALEXANDER SPRING RD
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:PA
Practice Address - Zip Code:17015-9129
Practice Address - Country:US
Practice Address - Phone:717-249-6337
Practice Address - Fax:717-249-2415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-25
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE7242T152W00000X
156FX1800X
PAMD032077E207W00000X
PAMD423128207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103079526Medicaid
PA103079526Medicaid