Provider Demographics
NPI:1811945736
Name:WAGNER, ROBERT G (DC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:G
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 N RAILROAD ST
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:PA
Mailing Address - Zip Code:17078-1720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 N RAILROAD ST
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:PA
Practice Address - Zip Code:17078-1720
Practice Address - Country:US
Practice Address - Phone:717-838-8889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC-3099-L111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
465539Medicare PIN