Provider Demographics
NPI:1932635653
Name:WAGNER, TRAVIS RAY (CAPT)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:RAY
Last Name:WAGNER
Suffix:
Gender:M
Credentials:CAPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86TH MEDICAL GROUP
Mailing Address - Street 2:UNIT 3215
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09094-3215
Mailing Address - Country:US
Mailing Address - Phone:804-337-9700
Mailing Address - Fax:
Practice Address - Street 1:86TH MEDICAL GROUP
Practice Address - Street 2:UNIT 3215
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09094-3215
Practice Address - Country:US
Practice Address - Phone:804-337-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-02
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014157341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice