Provider Demographics
NPI:1720179500
Name:WAGNER, KARL GORDON JR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KARL
Middle Name:GORDON
Last Name:WAGNER
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:57813 CIDER MILL DR
Mailing Address - Street 2:
Mailing Address - City:NEW HUDSON
Mailing Address - State:MI
Mailing Address - Zip Code:48165-9482
Mailing Address - Country:US
Mailing Address - Phone:248-486-4364
Mailing Address - Fax:
Practice Address - Street 1:22255 GREENFIELD RD
Practice Address - Street 2:SUITE 422
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3710
Practice Address - Country:US
Practice Address - Phone:248-849-3195
Practice Address - Fax:248-849-3390
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001954363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant