Basic Information
| Provider Information | |||||||||
| NPI: | 1942234851 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5074 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183335000 | ||||||||
| FaxNumber: | 2183335360 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 ANNE ST NW | ||||||||
| Address2: | |||||||||
| City: | BEMIDJI | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566015103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183335000 | ||||||||
| FaxNumber: | 2183335360 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 06/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 30763 | MN | Y | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 5910 | ND | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1700718 | 01 | ND | MEDICA # | OTHER | 198200100 | 05 | MN | MEDICAID | DA9011015601 | 01 | ND | PREFERRED ONE # | OTHER | 142077 | 01 | ND | UCARE # | OTHER | 676663 | 01 | ND | AMERICA'S PPO/ARAZ # | OTHER | HP25793 | 01 | ND | HEALTHPARTNERS # | OTHER | 1700497 | 01 | ND | MEDICA # | OTHER | ND200073 | 01 | ND | LHS # | OTHER | 28133WA | 01 | ND | MNBS # | OTHER |