Provider Demographics
NPI:1588001713
Name:WAGNER, OLIVER S (MD)
Entity type:Individual
Prefix:DR
First Name:OLIVER
Middle Name:S
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 1:555 N DUKE ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-2250
Mailing Address - Country:US
Mailing Address - Phone:717-544-7228
Mailing Address - Fax:717-544-4149
Practice Address - Street 1:555 N DUKE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2250
Practice Address - Country:US
Practice Address - Phone:717-544-7228
Practice Address - Fax:717-544-4149
Is Sole Proprietor?:No
Enumeration Date:2013-05-29
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD457567207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine