Provider Demographics
NPI:1881635159
Name:WAGNER, JOHN ADAM (DC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ADAM
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 1:411 HYDE PARK
Mailing Address - Street 2:
Mailing Address - City:DOYLESTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18902-6619
Mailing Address - Country:US
Mailing Address - Phone:215-230-8100
Mailing Address - Fax:215-230-8892
Practice Address - Street 1:411 HYDE PARK
Practice Address - Street 2:
Practice Address - City:DOYLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:18902-6619
Practice Address - Country:US
Practice Address - Phone:215-230-8100
Practice Address - Fax:215-230-8892
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC006590L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA139895OtherMEDICARE PTAN