Provider Demographics
NPI:1811597792
Name:WAGNER, ALAN
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:795 S TOWNSHIP ROAD 113
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-9791
Mailing Address - Country:US
Mailing Address - Phone:419-987-4440
Mailing Address - Fax:
Practice Address - Street 1:795 S TOWNSHIP ROAD 113
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-9791
Practice Address - Country:US
Practice Address - Phone:419-987-4440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7401270253Z00000X, 347C00000X, 3747P1801X, 385H00000X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No253Z00000XAgenciesIn Home Supportive Care
No347C00000XTransportation ServicesPrivate Vehicle
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No385H00000XRespite Care FacilityRespite Care