Provider Demographics
NPI:1619741121
Name:WAGERS, WESLEY
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:WAGERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1652 NEVADA AVE
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-2920
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1652 NEVADA AVE
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-2920
Practice Address - Country:US
Practice Address - Phone:606-767-7390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1203642175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty