Provider Demographics
NPI:1821030669
Name:WAGNER, JAMISON MATTHEW (DC)
Entity Type:Individual
Prefix:DR
First Name:JAMISON
Middle Name:MATTHEW
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 1:1928 S SEGUIN AVE
Mailing Address - Street 2:#104
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-3910
Mailing Address - Country:US
Mailing Address - Phone:830-627-7771
Mailing Address - Fax:
Practice Address - Street 1:1928 S SEGUIN AVE
Practice Address - Street 2:#104
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-3910
Practice Address - Country:US
Practice Address - Phone:830-627-7771
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10230111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI12266Medicare ID - Type Unspecified