Provider Demographics
NPI:1962750794
Name:VERNON, EDWARD WOLGRAM II (LAC)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:WOLGRAM
Last Name:VERNON
Suffix:II
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2358 PLANK RD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-4900
Mailing Address - Country:US
Mailing Address - Phone:540-847-6985
Mailing Address - Fax:
Practice Address - Street 1:2358 PLANK RD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4900
Practice Address - Country:US
Practice Address - Phone:540-847-6985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 12973171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist