Provider Demographics
NPI:1407684400
Name:WAGNER, WILLIAM (PA-C)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 FRANKLIN AVE APT 6O
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10601-3857
Mailing Address - Country:US
Mailing Address - Phone:845-554-4757
Mailing Address - Fax:
Practice Address - Street 1:5141 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-1159
Practice Address - Country:US
Practice Address - Phone:212-932-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-23
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032380363A00000X, 207X00000X
NJ363A00000X, 363AS0400X
NY363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical