1649683939 NPI number — LYLE WALTER WAGNER III PHD, LP

Table of content: LYLE WALTER WAGNER III PHD, LP (NPI 1649683939)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649683939 NPI number — LYLE WALTER WAGNER III PHD, LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGNER
Provider First Name:
LYLE
Provider Middle Name:
WALTER
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
PHD, LP
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:
1649683939
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
220 RAILROAD ST SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINE CITY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55063-1540
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-629-7600
Provider Business Mailing Address Fax Number:
651-925-0071

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3907 COON RAPIDS BLVD NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COON RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55433-2520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-629-7600
Provider Business Practice Location Address Fax Number:
651-925-0071
Provider Enumeration Date:
06/04/2014

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: 103TC0700X , with the licence number:  5751 , 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)





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