Provider Demographics
NPI:1134372980
Name:WAGNER, RYAN SCOTT (MD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:SCOTT
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 1:140 HILL ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:BUCYRUS
Mailing Address - State:OH
Mailing Address - Zip Code:44820-1566
Mailing Address - Country:US
Mailing Address - Phone:419-562-5281
Mailing Address - Fax:
Practice Address - Street 1:140 HILL ST
Practice Address - Street 2:SUITE B
Practice Address - City:BUCYRUS
Practice Address - State:OH
Practice Address - Zip Code:44820-1566
Practice Address - Country:US
Practice Address - Phone:419-562-5281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-24
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.096738207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2263161Medicaid