Provider Demographics
NPI:1669512000
Name:JAMES P. VANWAGNER D.O., P.C.
Entity Type:Organization
Organization Name:JAMES P. VANWAGNER D.O., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:PARKER
Authorized Official - Last Name:VANWAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:231-935-0957
Mailing Address - Street 1:5246 N ROYAL DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-6984
Mailing Address - Country:US
Mailing Address - Phone:231-935-0957
Mailing Address - Fax:231-935-0960
Practice Address - Street 1:5246 N ROYAL DR
Practice Address - Street 2:SUITE A
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-6984
Practice Address - Country:US
Practice Address - Phone:231-935-0957
Practice Address - Fax:231-935-0960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJV009579207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty