Provider Demographics
NPI:1336135243
Name:WAGGENSPACK, GERARD ALAN (MD)
Entity Type:Individual
Prefix:
First Name:GERARD
Middle Name:ALAN
Last Name:WAGGENSPACK
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 1:629D LOWTHER RD
Mailing Address - Street 2:
Mailing Address - City:LEWISBERRY
Mailing Address - State:PA
Mailing Address - Zip Code:17339-9527
Mailing Address - Country:US
Mailing Address - Phone:717-938-2765
Mailing Address - Fax:717-932-3095
Practice Address - Street 1:1001 S GEORGE ST
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-3676
Practice Address - Country:US
Practice Address - Phone:717-851-4624
Practice Address - Fax:717-851-3431
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD043215E2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001153372Medicaid
PA557111Medicare ID - Type Unspecified
C67325Medicare UPIN