Provider Demographics
NPI:1467536797
Name:WAGNER, CLIFFORD GERARD (DC)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:GERARD
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 1:53 WOODRUFF STREET
Mailing Address - Street 2:
Mailing Address - City:SARANAC LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12983
Mailing Address - Country:US
Mailing Address - Phone:518-891-1326
Mailing Address - Fax:518-891-1326
Practice Address - Street 1:53 WOODRUFF STREET
Practice Address - Street 2:
Practice Address - City:SARANAC LAKE
Practice Address - State:NY
Practice Address - Zip Code:12983
Practice Address - Country:US
Practice Address - Phone:518-891-1326
Practice Address - Fax:518-891-1326
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX0069381111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCO69387OtherWORKERS COMPENSATION
53319BMedicare ID - Type Unspecified