Provider Demographics
NPI:1336499888
Name:WAGNER, JOSEPH F (NP)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:F
Last Name:WAGNER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 MCHENRY ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-1838
Mailing Address - Country:US
Mailing Address - Phone:262-767-6100
Mailing Address - Fax:
Practice Address - Street 1:252 MCHENRY ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1838
Practice Address - Country:US
Practice Address - Phone:262-767-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-12
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4986363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100025339Medicaid