Provider Demographics
NPI:1386643310
Name:WAGNER, ETHAN E (DO)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:E
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 1:2015 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46016-4337
Mailing Address - Country:US
Mailing Address - Phone:765-646-8439
Mailing Address - Fax:765-646-8578
Practice Address - Street 1:2015 JACKSON ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-4337
Practice Address - Country:US
Practice Address - Phone:765-646-8439
Practice Address - Fax:765-646-8578
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002898A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000514519OtherBLUE CROSS /ANTHEM
IN000000514519OtherBLUE CROSS /ANTHEM
IN197620ZMedicare PIN