Provider Demographics
NPI:1316904345
Name:WAGNER, CHARLES ALLEN JR (DO)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:ALLEN
Last Name:WAGNER
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:300 HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:ORWIGSBURG
Practice Address - State:PA
Practice Address - Zip Code:17961-2426
Practice Address - Country:US
Practice Address - Phone:570-366-1557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008546L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016970330010Medicaid
PA951300YEBKMedicare PIN
PA951300YUNMMedicare UPIN
PAG48923Medicare UPIN
PA0016970330010Medicaid