Provider Demographics
NPI:1194266734
Name:WAGNER, ROBERT
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 MISERY MOUNTAIN LN
Mailing Address - Street 2:
Mailing Address - City:CROYDON
Mailing Address - State:NH
Mailing Address - Zip Code:03773-6617
Mailing Address - Country:US
Mailing Address - Phone:603-443-0290
Mailing Address - Fax:
Practice Address - Street 1:15 MISERY MOUNTAIN LN
Practice Address - Street 2:
Practice Address - City:CROYDON
Practice Address - State:NH
Practice Address - Zip Code:03773-6617
Practice Address - Country:US
Practice Address - Phone:603-443-0290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications