Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 35.093321 | OH |
Y | 2080P0204X | Pediatric Emergency Doctor | 01072502A | IN |
NPI | 1083821029 |
---|---|
Provider Name | Brian Eugene Wagers |
First Address | Indianapolis, IN 46219-4959 |
Second Address | Indianapolis, IN 46202-5109 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2007 |
Last Update Date | 06/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200956440 | (05) | IN |