Provider Demographics
NPI:1942374210
Name:WAGNER, MARK DARREL
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DARREL
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 E 34TH ST
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-2909
Mailing Address - Country:US
Mailing Address - Phone:218-362-7100
Mailing Address - Fax:218-362-7131
Practice Address - Street 1:1120 E 34TH ST
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-2909
Practice Address - Country:US
Practice Address - Phone:218-362-7100
Practice Address - Fax:218-362-7131
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30642207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN701083400Medicaid
MN701083400Medicaid
MN089002401Medicare PIN