Provider Demographics
NPI:1437235934
Name:WAGNER, BARRY D (DC)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:D
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 INTERSTATE LOOP
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0510
Mailing Address - Country:US
Mailing Address - Phone:701-223-5001
Mailing Address - Fax:701-223-4709
Practice Address - Street 1:1431 INTERSTATE LOOP
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0510
Practice Address - Country:US
Practice Address - Phone:701-223-5001
Practice Address - Fax:701-223-4709
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND061111N00000X
CO3494111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19785OtherBCBS OF ND
ND17241Medicaid
U32827Medicare UPIN
ND17241Medicaid