Provider Demographics
NPI:1790225720
Name:WAGNER, COMFORT (DC)
Entity Type:Individual
Prefix:
First Name:COMFORT
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20010 75TH AVE N
Mailing Address - Street 2:
Mailing Address - City:CORCORAN
Mailing Address - State:MN
Mailing Address - Zip Code:55340-9459
Mailing Address - Country:US
Mailing Address - Phone:763-416-4878
Mailing Address - Fax:
Practice Address - Street 1:20010 75TH AVE N
Practice Address - Street 2:
Practice Address - City:CORCORAN
Practice Address - State:MN
Practice Address - Zip Code:55340-9459
Practice Address - Country:US
Practice Address - Phone:763-416-4878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-23
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6324111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor