Provider Demographics
NPI:1861029779
Name:WAGNER, CHRISTOPHER JOSEPH (DO)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:JOSEPH
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 1:1964 N BLUE WATER CT
Mailing Address - Street 2:
Mailing Address - City:SUTTONS BAY
Mailing Address - State:MI
Mailing Address - Zip Code:49682-9745
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:309-655-7768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program