Provider Demographics
NPI:1821199126
Name:WAGENBLAST, SETH ANDREW (DC)
Entity Type:Individual
Prefix:DR
First Name:SETH
Middle Name:ANDREW
Last Name:WAGENBLAST
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 1:3924 WALSH RANCH BLVD
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-2441
Mailing Address - Country:US
Mailing Address - Phone:512-284-9278
Mailing Address - Fax:512-284-9283
Practice Address - Street 1:102 E MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-5200
Practice Address - Country:US
Practice Address - Phone:512-284-9278
Practice Address - Fax:512-284-9283
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9995111N00000X, 111NR0400X, 111NS0005X, 111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111NS0005XChiropractic ProvidersChiropractorSports Physician
No111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F21910Medicare PIN