1235134388 NPI number — MR. ALLAN HOWARD WAGNER RPH

Table of content: MR. ALLAN HOWARD WAGNER RPH (NPI 1235134388)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235134388 NPI number — MR. ALLAN HOWARD WAGNER RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGNER
Provider First Name:
ALLAN
Provider Middle Name:
HOWARD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
RPH
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:
1235134388
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 LINK CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW CITY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10956-1623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-639-6699
Provider Business Mailing Address Fax Number:
845-639-6699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7635 SOUTHAMPTON TER
Provider Second Line Business Practice Location Address:
APT 115
Provider Business Practice Location Address City Name:
TAMARAC
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33321-9134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-512-6255
Provider Business Practice Location Address Fax Number:
954-726-2509
Provider Enumeration Date:
06/16/2005

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: 183500000X , with the licence number:  PS12127 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 183500000X , with the licence number: 022280-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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