Provider Demographics
NPI:1992744270
Name:WAGNER, ANDREW (MD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 NEFF AVE
Mailing Address - Street 2:
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22801-3439
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2010 HEALTH CAMPUS DRIVE
Practice Address - Street 2:
Practice Address - City:HARRISONBURG
Practice Address - State:VA
Practice Address - Zip Code:22801-3248
Practice Address - Country:US
Practice Address - Phone:540-689-1000
Practice Address - Fax:540-434-0550
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010591292085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7220065Medicaid
VA7220065Medicaid
VA300002155Medicare ID - Type Unspecified