Provider Demographics
NPI:1740229566
Name:WAGNER, TREVOR JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:TREVOR
Middle Name:JOHN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6411 S 172ND AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68135-3080
Mailing Address - Country:US
Mailing Address - Phone:402-891-1249
Mailing Address - Fax:402-334-0891
Practice Address - Street 1:2639 S 159TH PLZ
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-1705
Practice Address - Country:US
Practice Address - Phone:402-334-4700
Practice Address - Fax:402-334-0891
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1125111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE36615OtherBLUE CROSS/BLUE SHIELD
NE47-0802260 05Medicaid
NE36615OtherBLUE CROSS/BLUE SHIELD
NEU55848Medicare UPIN