Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0800X | Chiropractor Orthopedic Specialist | DC-3099-L | PA |
NPI | 1811945736 |
---|---|
Provider Name | Robert G. Wagner |
First Address | Palmyra, PA 17078-1720 |
Second Address | Palmyra, PA 17078-1720 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/05/2006 |
Last Update Date | 04/04/2008 |