Provider Demographics
NPI:1215923156
Name:WAGNER, TIMOTHY JOHN (DC, BS)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JOHN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DC, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 N DURKEE ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5427
Mailing Address - Country:US
Mailing Address - Phone:920-830-2225
Mailing Address - Fax:920-830-2221
Practice Address - Street 1:118 N DURKEE ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-5427
Practice Address - Country:US
Practice Address - Phone:920-830-2225
Practice Address - Fax:920-830-2221
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-26
Last Update Date:2007-07-08
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
WI4002-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU99721Medicare UPIN