Provider Demographics
NPI:1518901990
Name:WAGNER, PAUL D (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:D
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 GARFIELD AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-5340
Mailing Address - Country:US
Mailing Address - Phone:304-420-7161
Mailing Address - Fax:
Practice Address - Street 1:3200 MACCORKLE AVENUE SE
Practice Address - Street 2:HOSPITALISTS PROGRAM
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304
Practice Address - Country:US
Practice Address - Phone:304-388-5848
Practice Address - Fax:304-388-9654
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001325207R00000X
WV23276207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCH38233Medicare UPIN
WA7386531Medicare PIN
P00844006Medicare PIN
WA4280681Medicare PIN
NC2037558Medicare ID - Type Unspecified