Provider Demographics
NPI:1093510810
Name:WAGNER, JACK C
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:C
Last Name:WAGNER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 STANTON L YOUNG BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5018
Mailing Address - Country:US
Mailing Address - Phone:405-271-2316
Mailing Address - Fax:
Practice Address - Street 1:2200 N CLASSEN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-5800
Practice Address - Country:US
Practice Address - Phone:405-760-2673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-17
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program