Provider Demographics
NPI:1851841027
Name:WAGNER, JOSEPH
Entity Type:Individual
Prefix:
First Name:JOSEPH
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 1:33 WYOMING VALLEY MALL
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-6810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:33 WYOMING VALLEY MALL
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-6810
Practice Address - Country:US
Practice Address - Phone:570-819-1611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003228152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist