Provider Demographics
NPI:1932282878
Name:WAGONER, GARY L (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:WAGONER
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:PO BOX 9616
Mailing Address - Street 2:
Mailing Address - City:CHANDLER HEIGHTS
Mailing Address - State:AZ
Mailing Address - Zip Code:85227
Mailing Address - Country:US
Mailing Address - Phone:480-343-0585
Mailing Address - Fax:480-635-1719
Practice Address - Street 1:1337 S GILBERT RD STE 105
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204
Practice Address - Country:US
Practice Address - Phone:480-343-0585
Practice Address - Fax:480-635-1719
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28876111NR0400X
AZ8098111NX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0100XChiropractic ProvidersChiropractorOccupational Health
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0288760OtherBLUE SHIELD