Provider Demographics
NPI:1639130446
Name:WAGNER, WILLIAM JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:JOHN
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 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:PO BOX 3127
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:531 BROAD ST
Practice Address - Street 2:
Practice Address - City:MONTOURSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17754-2338
Practice Address - Country:US
Practice Address - Phone:570-368-2235
Practice Address - Fax:570-368-3932
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD017074E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA157016OtherHIGHMARK BLUE SHIELD
PA001732OtherFIRST PRIORITY HEALTH
PA549006OtherAETNA
PA177506OtherUNITEDHEALTHCARE
PA0016382010001Medicaid
PAD71334OtherHEALTHAMERICA
PA549006OtherAETNA
PA0016382010001Medicaid