Provider Demographics
NPI:1346221041
Name:WAGNER, JOHN S (DC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3778 UNION ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4453
Mailing Address - Country:US
Mailing Address - Phone:765-448-1674
Mailing Address - Fax:
Practice Address - Street 1:3778 UNION ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4453
Practice Address - Country:US
Practice Address - Phone:765-448-1674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08000532A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000197485OtherBLUE CROSS/BLUE SHIELD
IN100262580Medicaid
IN350039779Medicare PIN
IN920610Medicare PIN