Provider Demographics
NPI:1932448347
Name:WAGNER, JERAD SCOTT (PA-C)
Entity type:Individual
Prefix:
First Name:JERAD
Middle Name:SCOTT
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 1:921 14TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1837
Mailing Address - Country:US
Mailing Address - Phone:580-223-5311
Mailing Address - Fax:580-223-8227
Practice Address - Street 1:921 14TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1837
Practice Address - Country:US
Practice Address - Phone:580-223-5311
Practice Address - Fax:580-223-8227
Is Sole Proprietor?:No
Enumeration Date:2013-02-05
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2197363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2197OtherPHYSICIAN ASSISTANT LICENSE