Provider Demographics
NPI:1508079138
Name:WAGONER, WAYNE L (DPM)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:L
Last Name:WAGONER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 ROSEMERE LN
Mailing Address - Street 2:
Mailing Address - City:MAQUOKETA
Mailing Address - State:IA
Mailing Address - Zip Code:52060-2615
Mailing Address - Country:US
Mailing Address - Phone:563-652-9777
Mailing Address - Fax:563-652-9778
Practice Address - Street 1:515 ROSEMERE LN
Practice Address - Street 2:
Practice Address - City:MAQUOKETA
Practice Address - State:IA
Practice Address - Zip Code:52060-2615
Practice Address - Country:US
Practice Address - Phone:563-652-9777
Practice Address - Fax:563-652-9778
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00526213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1083683Medicaid
IA1083683Medicaid