Provider Demographics
NPI:1194703793
Name:WAGNER, ANDREW STANDISH (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:STANDISH
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5400 MACKINAW RD
Mailing Address - Street 2:SUITE 6100
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604-9515
Mailing Address - Country:US
Mailing Address - Phone:989-792-3100
Mailing Address - Fax:989-792-9860
Practice Address - Street 1:4401 CAMPUS RIDGE DR STE LL110
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6126
Practice Address - Country:US
Practice Address - Phone:989-837-9400
Practice Address - Fax:989-792-9860
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076172207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10 4203718Medicaid
P105248OtherBLUE CARE NETWORK ID #
MI10 4203718Medicaid
MIOG36041Medicare ID - Type Unspecified