Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 14543 | MD |
Y | 213EG0000X | General Practice | 14543 | MD |
NPI | 1003044173 |
---|---|
Provider Name | Stephen Thomas Wagner |
First Address | Salisbury, MD 21802-1978 |
Second Address | Princess Anne, MD 21853-1358 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/06/2009 |
Last Update Date | 25/01/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
119591300 | (05) | MD |