Provider Demographics
NPI:1619303104
Name:WAGNER, JON-ERIK (MD)
Entity Type:Individual
Prefix:
First Name:JON-ERIK
Middle Name:
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 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2580
Mailing Address - Country:US
Mailing Address - Phone:607-763-6075
Mailing Address - Fax:607-763-5234
Practice Address - Street 1:40 ARCH ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2102
Practice Address - Country:US
Practice Address - Phone:607-763-6075
Practice Address - Fax:607-763-5234
Is Sole Proprietor?:No
Enumeration Date:2013-09-17
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program