Provider Demographics
NPI:1598734196
Name:WAGNER, PETER B (DO)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:B
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751069
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 HEART DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-8982
Practice Address - Country:US
Practice Address - Phone:252-744-4400
Practice Address - Fax:252-744-3987
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9500471207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC85205OtherBCBS
NC8985205Medicaid
NC060033560OtherRAILROAD MEDICARE
NC58761OtherMEDCOST
561638624OtherCOMMERCIAL PAYERS
NC58761OtherMEDCOST
NC2213026Medicare PIN