Provider Demographics
NPI:1194720748
Name:WAGNER, BRENT J (MD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 S 7TH AVE
Mailing Address - Street 2:STE 135
Mailing Address - City:WEST READING
Mailing Address - State:PA
Mailing Address - Zip Code:19611-1442
Mailing Address - Country:US
Mailing Address - Phone:610-988-8919
Mailing Address - Fax:610-988-8400
Practice Address - Street 1:301 S 7TH AVE
Practice Address - Street 2:STE 135
Practice Address - City:WEST READING
Practice Address - State:PA
Practice Address - Zip Code:19611-1442
Practice Address - Country:US
Practice Address - Phone:610-988-8919
Practice Address - Fax:610-988-8400
Is Sole Proprietor?:No
Enumeration Date:2005-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-038170-E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01692458Medicaid
PA01692458Medicaid
PAWA011846Medicare ID - Type Unspecified