Provider Demographics
NPI:1992058556
Name:WAGNER, DYLAN PAUL (PA)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:PAUL
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-649-2775
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:2313 HIGHWAY 15 N
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-1805
Practice Address - Country:US
Practice Address - Phone:601-649-2775
Practice Address - Fax:601-649-2686
Is Sole Proprietor?:No
Enumeration Date:2012-10-19
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00172363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS5874982OtherCIGNA
MS05153323Medicaid
MS9469937OtherAETNA
MS3528936OtherUNITED HEALTHCARE
MS5874982OtherCIGNA