Provider Demographics
NPI:1992775027
Name:WAGNER, JONI (PA-C)
Entity type:Individual
Prefix:MS
First Name:JONI
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA-C
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 86430
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57118-6430
Mailing Address - Country:US
Mailing Address - Phone:605-322-4900
Mailing Address - Fax:605-322-4925
Practice Address - Street 1:740 S HILL ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:SD
Practice Address - Zip Code:57058-8760
Practice Address - Country:US
Practice Address - Phone:605-425-2855
Practice Address - Fax:605-425-2149
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0481363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD01-11971OtherMEDICA
SDS1639OtherMEDICARE PTAN
SD2843OtherAVERA HEALTH
SD234724OtherMIDLAND'S CHOICE
SD9238086OtherDAKOTACARE
SDHP34870OtherHEALTH PARTNERS
SD4997236OtherWELLMARK
SD6823310Medicaid
SDAH1311029419OtherPREFERRED ONE
SDAH1311029419OtherPREFERRED ONE
SD6823310Medicaid