Provider Demographics
NPI:1376519587
Name:WAGNER, WILLIAM J (DO)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N7426 COUNTY ROAD J
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073-2741
Mailing Address - Country:US
Mailing Address - Phone:920-876-2241
Mailing Address - Fax:
Practice Address - Street 1:N7426 COUNTY ROAD J
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073-2741
Practice Address - Country:US
Practice Address - Phone:920-876-2241
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21098207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIB57404Medicare UPIN