Provider Demographics
NPI:1568580801
Name:WAGNER, WAYNE PAUL (DC)
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:PAUL
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 N SPENCE AVE
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-4263
Mailing Address - Country:US
Mailing Address - Phone:919-751-0555
Mailing Address - Fax:919-751-3001
Practice Address - Street 1:605 N SPENCE AVE
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-4263
Practice Address - Country:US
Practice Address - Phone:919-751-0555
Practice Address - Fax:919-751-3001
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4617111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX009027OtherLICENSE
NYX3C561Medicare ID - Type Unspecified