Basic Information
| Provider Information | |||||||||
| NPI: | 1972594471 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 940 NE 13TH ST | ||||||||
| Address2: | SUITE 4G4250 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731045008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052715125 | ||||||||
| FaxNumber: | 4052713462 | ||||||||
| Practice Location | |||||||||
| Address1: | 940 NE 13TH ST | ||||||||
| Address2: | SUITE 4G4250 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731045008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052715125 | ||||||||
| FaxNumber: | 4052713462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 04/24/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 24510 | OK | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.