Provider Demographics
NPI:1295897437
Name:WAGNER, DAVID KENT (CSA, OPA)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:KENT
Last Name:WAGNER
Suffix:
Gender:M
Credentials:CSA, OPA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1008 TAVERN ROAD
Mailing Address - Street 2:STE 102
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-2864
Mailing Address - Country:US
Mailing Address - Phone:304-263-5129
Mailing Address - Fax:
Practice Address - Street 1:1008 TAVERN ROAD
Practice Address - Street 2:STE 102
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2864
Practice Address - Country:US
Practice Address - Phone:304-263-5129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical