Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | 20111 | WI |
NPI | 1073576336 |
---|---|
Provider Name | Dr. Richard F Wagner |
First Address | Mount Pleasant, WI 53403-4416 |
Second Address | Burlington, WI 53105-1828 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/04/2006 |
Last Update Date | 05/04/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
30773500 | (05) | WI |
B57399 | (02) | WI |