Provider Demographics
NPI:1205933595
Name:WAGNER, JOHN E (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:420 DELAWARE ST SE
Mailing Address - Street 2:MMC 692,UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0341
Mailing Address - Country:US
Mailing Address - Phone:612-626-2663
Mailing Address - Fax:
Practice Address - Street 1:516 DELAWARE ST SE
Practice Address - Street 2:PWB FIFTH FLOOR, SUITE 5-100, CLINIC 5B
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0356
Practice Address - Country:US
Practice Address - Phone:612-626-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN34354208000000X, 2080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN090290OtherFAIRVIEW
MN100981OtherUCARE
MN837207100Medicaid
LA1896241Medicaid
MN2T332WAOtherBLUE CROSS BLUE SHIELD
IA1970657Medicaid
KS2086719201Medicaid
ND10387Medicaid
WI1688300Medicaid
MN3624608OtherMEDICA - CHOICE
MN3674548OtherMEDICA - PRIMARY
MNHP22006OtherHEALTHPARTNERS
MN1009344OtherPREFERREDONE
MN768393OtherARAZ
SD7777470Medicaid
KS2086719201Medicaid
MN768393OtherARAZ