Provider Demographics
NPI:1376808071
Name:VANWAGNEN, JON CHRISTOPHER (OD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:CHRISTOPHER
Last Name:VANWAGNEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 PARKER AVE
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707-1413
Mailing Address - Country:US
Mailing Address - Phone:989-916-6168
Mailing Address - Fax:
Practice Address - Street 1:137 PARKER AVE
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1413
Practice Address - Country:US
Practice Address - Phone:989-916-6168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004725152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist