Provider Demographics
NPI:1942234851
Name:WAGNER, JAMES S (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:S
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
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 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:218-333-5000
Mailing Address - Fax:218-333-5360
Practice Address - Street 1:1300 ANNE ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5103
Practice Address - Country:US
Practice Address - Phone:218-333-5000
Practice Address - Fax:218-333-5360
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30763208600000X
ND5910208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1700718OtherMEDICA #
MN198200100Medicaid
NDDA9011015601OtherPREFERRED ONE #
ND142077OtherUCARE #
ND676663OtherAMERICA'S PPO/ARAZ #
NDHP25793OtherHEALTHPARTNERS #
ND1700497OtherMEDICA #
NDND200073OtherLHS #
ND28133WAOtherMNBS #
ND1700718OtherMEDICA #
ND020021741Medicare UPIN
ND10052Medicare ID - Type UnspecifiedND MEDICARE #
MNN713581Medicare PIN