Provider Demographics
NPI:1477941151
Name:WAGNER, ADAM
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
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 1:3400 1ST ST N STE 105
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1924
Mailing Address - Country:US
Mailing Address - Phone:320-774-1355
Mailing Address - Fax:
Practice Address - Street 1:3400 1ST ST N STE 105
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1924
Practice Address - Country:US
Practice Address - Phone:320-774-1355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-02
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNT5302554888082255A2300X
MN6987111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer