Provider Demographics
NPI:1275504078
Name:WAGNER, GEORGE C (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:C
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 1:2930 TREE SWALLOW RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-5024
Mailing Address - Country:US
Mailing Address - Phone:540-354-3159
Mailing Address - Fax:
Practice Address - Street 1:2930 TREE SWALLOW RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-5024
Practice Address - Country:US
Practice Address - Phone:540-354-3159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051795207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine