1205933595 NPI number — JOHN E WAGNER MD

Table of content: JOHN E WAGNER MD (NPI 1205933595)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205933595 NPI number — JOHN E WAGNER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGNER
Provider First Name:
JOHN
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205933595
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 DELAWARE ST SE
Provider Second Line Business Mailing Address:
MMC 692,UNIVERSITY OF MINNESOTA PHYSICIANS
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55455-0341
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-626-2663
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
516 DELAWARE ST SE
Provider Second Line Business Practice Location Address:
PWB FIFTH FLOOR, SUITE 5-100, CLINIC 5B
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55455-0356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-626-2663
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  34354 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0207X , with the licence number: 34354 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 090290 . This is a "FAIRVIEW" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 100981 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 837207100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1896241 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2T332WA . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1970657 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2086719201 , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10387 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1688300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3624608 . This is a "MEDICA - CHOICE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 3674548 . This is a "MEDICA - PRIMARY" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP22006 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1009344 . This is a "PREFERREDONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 768393 . This is a "ARAZ" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 7777470 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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