Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | OEG000125 | PA |
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | OEG000125 | PA |
N | 152WL0500X | Optomitrist - Low Vision Rehabilitation | OEG000125 | PA |
N | 152WP0200X | Pediatric Optomitrist | OEG000125 | PA |
N | 152WV0400X | Optomitrist - Vision Therapist | OEG000125 | PA |
N | 152WX0102X | Occupational Vision | OEG000125 | PA |
NPI | 1295754778 |
---|---|
Provider Name | Dr. David A Wagner |
First Address | Seneca, PA 16346-2529 |
Second Address | Seneca, PA 16346-2529 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/07/2006 |
Last Update Date | 25/07/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0018040170003 | (05) | PA |
U80736 | (02) | PA |