Basic Information
| Provider Information | |||||||||
| NPI: | 1346373446 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | T. | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1735 27TH ST STE B06 | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456622681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403568681 | ||||||||
| FaxNumber: | 7403537900 | ||||||||
| Practice Location | |||||||||
| Address1: | 1248 KINNEYS LN | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456622994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403567290 | ||||||||
| FaxNumber: | 7403567938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 09/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 34003690W | OH | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 34.003690 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0557642 | 05 | OH | MEDICAID |