Basic Information
| Provider Information | |||||||||
| NPI: | 1811129547 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | RUSSELL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 253 W 72ND ST APT 1703 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100232709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029942479 | ||||||||
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| Practice Location | |||||||||
| Address1: | 234 E 149TH ST | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104515504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185795717 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2009 | ||||||||
| LastUpdateDate: | 02/03/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 270163 | NY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.