1770749541 NPI number — EARL JASON WAGNER SUBMARINE IDC

Table of content: EARL JASON WAGNER SUBMARINE IDC (NPI 1770749541)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770749541 NPI number — EARL JASON WAGNER SUBMARINE IDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGNER
Provider First Name:
EARL
Provider Middle Name:
JASON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SUBMARINE IDC
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:
1770749541
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
79 HICKORY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GROTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06340-2910
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-449-9359
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
USS PITTSBURGH SSN-720
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FPO
Provider Business Practice Location Address State Name:
AE
Provider Business Practice Location Address Postal Code:
09582-2400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-694-3618
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/31/2008

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: 1710I1002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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