Provider Demographics
NPI:1750324802
Name:WAGNER, GREGORY P (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:P
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 1:10121 CARLINGTON VALLEY CT
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20111-2544
Mailing Address - Country:US
Mailing Address - Phone:707-241-5155
Mailing Address - Fax:
Practice Address - Street 1:500 HOSPITAL DR
Practice Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186
Practice Address - Country:US
Practice Address - Phone:540-316-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA096347207P00000X
VA0101246400207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine