Provider Demographics
NPI:1851658520
Name:WAGNER, SHAUN R (DO)
Entity Type:Individual
Prefix:DR
First Name:SHAUN
Middle Name:R
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MANNING DR
Mailing Address - Street 2:DEPARTMENT OF RADIOLOGY
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-4220
Mailing Address - Country:US
Mailing Address - Phone:919-966-2992
Mailing Address - Fax:919-962-9625
Practice Address - Street 1:101 MANNING DR
Practice Address - Street 2:DEPARTMENT OF RADIOLOGY
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-4220
Practice Address - Country:US
Practice Address - Phone:919-966-2992
Practice Address - Fax:919-962-9625
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-18
Last Update Date:2015-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-017262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology