Basic Information
| Provider Information | |||||||||
| NPI: | 1083848030 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | BRADFORD | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 GANNETT DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041065900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078280361 | ||||||||
| FaxNumber: | 2078741483 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 FODEN RD STE 3 | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041061718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078741489 | ||||||||
| FaxNumber: | 2075238590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2009 | ||||||||
| LastUpdateDate: | 10/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | MD19486 | ME | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | MD19486 | ME | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.