Provider Demographics
NPI:1497944813
Name:VANWAGNER, KRIS ADWARDS (DO)
Entity Type:Individual
Prefix:
First Name:KRIS
Middle Name:ADWARDS
Last Name:VANWAGNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:50 LEROY ST
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-1786
Mailing Address - Country:US
Mailing Address - Phone:315-274-9085
Mailing Address - Fax:315-274-9084
Practice Address - Street 1:49 LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-1889
Practice Address - Country:US
Practice Address - Phone:315-274-9085
Practice Address - Fax:315-274-9084
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY246425207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology