Provider Demographics
NPI:1437126984
Name:WAGNER, FREDERICK L (PA)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:L
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 CHANDLER AVE
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:14020-1611
Mailing Address - Country:US
Mailing Address - Phone:585-343-9676
Mailing Address - Fax:585-343-1047
Practice Address - Street 1:33 CHANDLER AVE
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-1611
Practice Address - Country:US
Practice Address - Phone:585-343-9676
Practice Address - Fax:585-343-1047
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004282-1207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYD70031Medicare ID - Type Unspecified
NYR53393Medicare UPIN