Provider Demographics
NPI:1326539578
Name:WAGNER, BRENTON PAUL (CNP)
Entity Type:Individual
Prefix:MR
First Name:BRENTON
Middle Name:PAUL
Last Name:WAGNER
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 E PORTAGE TRL APT 310
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44221-2868
Mailing Address - Country:US
Mailing Address - Phone:419-961-4784
Mailing Address - Fax:
Practice Address - Street 1:12300 MCCRACKEN ROAD
Practice Address - Street 2:
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44125
Practice Address - Country:US
Practice Address - Phone:216-581-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.022596363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily