Provider Demographics
NPI:1477875078
Name:WAGNER, ERIC N
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:N
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 W MARKET ST
Mailing Address - Street 2:STE7
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22902-5061
Mailing Address - Country:US
Mailing Address - Phone:434-293-7368
Mailing Address - Fax:434-293-5752
Practice Address - Street 1:218 W MARKET ST
Practice Address - Street 2:STE7
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-5061
Practice Address - Country:US
Practice Address - Phone:434-293-7368
Practice Address - Fax:434-293-5752
Is Sole Proprietor?:No
Enumeration Date:2010-02-23
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2101000735237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist