Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207PE0004X | Emergency Medical Services | 3719 | AZ |
Y | 207Q00000X | Family Doctor | 3719 | AZ |
NPI | 1134248867 |
---|---|
Provider Name | Donald J Wagner |
First Address | Bullhead City, AZ 86442-7100 |
Second Address | Bullhead City, AZ 86442-7100 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/03/2007 |
Last Update Date | 26/01/2016 |