Provider Demographics
NPI:1740201276
Name:WAGNER, PHILIP L (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:L
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2301 HOUSE AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3176
Mailing Address - Country:US
Mailing Address - Phone:307-634-5216
Mailing Address - Fax:307-638-6675
Practice Address - Street 1:2301 HOUSE AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3176
Practice Address - Country:US
Practice Address - Phone:307-634-5216
Practice Address - Fax:307-638-6675
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5171A207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY104211400Medicaid
WY104211400Medicaid
F27358Medicare UPIN