Provider Demographics
NPI:1881644292
Name:WAGNER, TIMOTHY ALLEN (DC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ALLEN
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 1:2016 W. HOUSTON
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012
Mailing Address - Country:US
Mailing Address - Phone:918-742-2094
Mailing Address - Fax:918-742-2095
Practice Address - Street 1:2016 W. HOUSTON
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012
Practice Address - Country:US
Practice Address - Phone:918-742-2094
Practice Address - Fax:918-742-2095
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3225111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U53868Medicare UPIN