Provider Demographics
NPI:1942766787
Name:WAGNER, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
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 1:200 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17046-5040
Mailing Address - Country:US
Mailing Address - Phone:717-272-5464
Mailing Address - Fax:
Practice Address - Street 1:26 MOUNT ZION RD
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-2601
Practice Address - Country:US
Practice Address - Phone:717-840-0984
Practice Address - Fax:717-755-8859
Is Sole Proprietor?:No
Enumeration Date:2019-02-18
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103620423Medicaid