Provider Demographics
NPI:1154413003
Name:WAGNER, ROBERT JOHN (DC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOHN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 N HAYNES AVE
Mailing Address - Street 2:
Mailing Address - City:MILES CITY
Mailing Address - State:MT
Mailing Address - Zip Code:59301-5615
Mailing Address - Country:US
Mailing Address - Phone:406-234-2225
Mailing Address - Fax:406-224-3500
Practice Address - Street 1:213 N HAYNES AVE
Practice Address - Street 2:
Practice Address - City:MILES CITY
Practice Address - State:MT
Practice Address - Zip Code:59301-5615
Practice Address - Country:US
Practice Address - Phone:406-234-2225
Practice Address - Fax:406-224-3500
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT742111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
011001346Medicare PIN