Provider Demographics
NPI:1891744967
Name:WAGNER, JEFFREY DOUGLAS (PA)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:DOUGLAS
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 RONALD LN
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-1622
Mailing Address - Country:US
Mailing Address - Phone:631-750-3924
Mailing Address - Fax:
Practice Address - Street 1:18 RONALD LN
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-1622
Practice Address - Country:US
Practice Address - Phone:631-750-3924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical