Provider Demographics
NPI:1689012684
Name:WAGNER, WILFORD TYREL (HIS)
Entity Type:Individual
Prefix:
First Name:WILFORD
Middle Name:TYREL
Last Name:WAGNER
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7317 N HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-4252
Mailing Address - Country:US
Mailing Address - Phone:847-588-1895
Mailing Address - Fax:
Practice Address - Street 1:7317 N HARLEM AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-4252
Practice Address - Country:US
Practice Address - Phone:847-588-1895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCHAS-0516237700000X
IL3115237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist